Symposium Introduction

Public debates about the role of religion in decisions about health and medicine can be vociferous. Consider what emerged in the disputes about Terri Schiavo’s medical care: those who called themselves “pro-life” protested outside her hospice, and courtroom battles between Schiavo’s parents and her husband sought to adjudicate how her Catholic faith would influence her medical care. More recently, some Christians, Muslims, and Jews have argued that they have a religious obligation to flout public health guidelines in order to obey God’s command to worship in person even amid the Covid-19 pandemic.

Michael and Traci Balboni’s staggeringly rich and wide-ranging book on the role of religion in American medicine contributes to such debates. As a team, they bring a wide range of expertise, Tracy is a radiation oncologist, and her husband, Michael, is a pastor and a practical theologian. Both have previously helped coauthor important empirical studies of patients’ desires for religious support at the end of life.1

The book combines sophisticated theology with often blistering critiques of how medicine in the United States has sidelined religious practice or substituted what the Balbonis see as a falsely claimed neutral alternative “spirituality.” They argue that in order for a patient’s religious values to be respected in the context of medicine, physicians must also learn new skills and practices that will help them understand their patient’s religious convictions so they can grasp how those convictions might alter decisions about what treatments they will accept or refuse. In addition, debates about conscience provisions for physicians that have been made part of federal regulation since the completion of the Balbonis’ manuscript have at least in the eyes of some allowed physicians to reclaim their own religious values in the context of their practices.

The responses in this symposium come from varied places. Asma Mobbin-Uddin writes as a Muslim pediatrician, who asks about how religious symbols are really encountered in medicine. Justin List, a medical ethicist and primary care physician in New York City, crafted his response as he worked on the frontlines of the Covid-19 pandemic. He asks whether we frame medicine as a gift or as a social contact. I write as a chaplain, wishing to push back on what I see as the Balbonis’ theological vision. I wonder whether it is practical, possible, or even necessary for physician and patient religious preferences to align, noting the evident dangers of attempting that alignment in a clinical encounter. Lydia Dugdale, a primary care physician in a large academic medical system, asks what changes are necessary to sustain clinicians who are increasingly driven by those who see medicine as an economic and not a spiritual exercise.

This rich conversation across issues of ethics, theology, and conversation prompted by the strong claims and concrete proposals hopefully will spark more conversations and thoughts among theologians and practitioners.


  1. See Tracy Anne Balboni et al., “Provision of Spiritual Care to Patients with Advanced Cancer: Associations with Medical Care and Quality of Life Near Death,” Journal of Clinical Oncology: Official Journal of the American Society of Clinical Oncology 28, no. 3 (January 20, 2010): 445–52, https://doi.org/10.1200/JCO.2009.24.8005; Michael J. Balboni et al., “Why Is Spiritual Care Infrequent at the End of Life? Spiritual Care Perceptions Among Patients, Nurses, and Physicians and the Role of Training,” Journal of Clinical Oncology: Official Journal of the American Society of Clinical Oncology 31, no. 4 (February 1, 2013): 461–67, https://doi.org/10.1200/JCO.2012.44.6443.

Response

Barriers to Pluralism

“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.

  • Michael and Tracy Balboni

    Reply

    It Does Not Answer or Save Him from His Trouble

    It is with sincere appreciation to Syndicate and to Aaron Klink for organizing this symposium and inviting responses to Hostility to Hospitality. Our responses generally represent our shared views, but not necessarily all.

    We greatly appreciate Dr. Mobin-Uddin for her sharing her reflections on Hostility to Hospitality. We have greatly benefited from learning from her in her public lectures, and we have had the delight to serve together with her as advisors for the Conference on Medicine and Religion (http://www.medicineandreligion.com/).

    We appear to largely agree on the ideal that patients receive spiritual care in a manner that is consistent with their beliefs. We agree that spiritual care must not be coercive or place subtle pressure on patients in any manner that infringes on the patient’s freedom. We presumably agree that clinicians should only freely provide spiritual care in a manner consistent with the clinician’s worldview. When it comes to spiritual interaction in the medical setting, the patient-clinician relationship and its context must be guided by a noncompulsory, voluntary arrangement. Of course, this was not a “how to” book, so we did not develop in-depth guidelines for clinicians or institutions. Yet the book generally outlines the centrality of human freedom within spirituality and why proselytism is intolerable in our understanding of structural pluralism (273–78). We appear to have many shared ways of understanding the relationship between medicine and spiritual care.

    We also welcome Dr. Mobin-Uddin’s personal reflections on the John Hopkins Christus Consolator statue. She concludes that the book’s brief analysis of this statue underappreciated the negative impact it has on those outside the Christian faith, leading to their likely alienation or intimidation. For her, the statue exemplifies how even people of goodwill still have too many blind spots, and that “othering” spiritual minorities, even without intention, is nearly certain. She argues that the statute is a symbolic example of how difficult or seemingly impossible it is to solve these issues, given the minefield of differences between spiritual traditions and our lack of accurate knowledge of one another.

    In response to her concerns, we offer three brief clarifications.

    First, in regard to the positive comments of the Christus Consolator statue, the book’s affirmative perspective values what the statue does under the current secular structure of medicine. Dr. Mobin-Uddin may have misunderstood our argument where she interpreted us as defending the statue as a future model for structural pluralism. We would certainly not recommend this. Rather, the statue is a positive nineteenth-century example highlighting how American medicine and religion attempted to exemplify a partnership rather than separation. It may still have some ongoing value assuming the status quo, that the secular hegemony continues to dominate medicine. We would prefer to have some transcendent marker remaining from a prior era, one that resonates with a fairly significant majority of patients in Baltimore, as preferable than no transcendent symbol at all.

    Second, on a personal note, we share a deep concern about spiritual and religious minorities being caused significant discomfort by spiritual signs and symbols. We appreciate Dr. Mobin-Uddin’s willingness to personally reflect on the ways that encountering a statue would impact her. What might be a surprise is that Michael comes from a Christian heritage that is iconoclast, which values plain and simple spaces free of religious ornamentation. The reasons for this position are fairly similar to an Islamic concern, which views images of the Divine as a form of idol making. Thus, our evaluation of the Christus Consolator statue was written at least partly from the personal viewpoint as an outsider.

    Pluralism itself generates discomfort as we become more aware that each of us is an “other.” Within pluralism’s dance, traditions must aspire toward humility and patience even when enduring views and practices (and statutes!) of traditions considered theologically askew or even morally repugnant. As we engage diversity, pluralism requires understanding through dialogue, being stretched beyond what is understood or misunderstood, and encountering the commitments of others within relationships. So the move we are proposing is not toward making spiritual minorities comfortable. Pluralism creates discomfort and alienation for us all. This is the downside of multiple traditions operating within the same institution. Its upside is that through increased understanding of our different deep commitments, we will learn how to defend the other, and make space for one another, even as we continue to disagree and cause one another a great deal of discomfort. We do not see any way around this dynamic. We wrote positively about the Christus Consolator, despite our own theological hesitancies, as a way to appreciate but not necessarily endorse the spiritual practices of others. Pluralism demands that we all learn how to do this, and we are certainly still learning.

    Third, we worry that readers might conclude that the book’s central point is that we want hospitals to have a few religious symbols in its public hallways. This is not our primary concern. Our chief criticism was that secular social structures in medicine are not neutral, but have latent, mostly unrecognized, theological commitments. Staying with the religious statues as an example, a secular approach has avoided public symbols in order to formally keep medical space neutral for patients and clinicians. Conversely, we argue that the absence of religious symbols represents a dearth of less obvious, but far more impactful structures, with spiritual implications. Based upon Charles Taylor’s concept of the immanent frame, we argue that medicine’s deep structures (time, economics, professional roles and competencies, and space) reflect an underlying immanence (111ff.). Immanence has transformed hospital institutions in its authority structure and institutional mission. It alters epistemological assumptions about relevant knowledge and skills related to clinical formation and guild competencies. And immanence has transformed our experience of time and space, eliminating transcendent markers. The secular framework privatizes religion in the illness experience, contending that religious privatization is neutral. We contend that religious privatization is swimming upstream against the strong current of immanence. The larger point is not to quarrel over the impact of a particular religious symbol and statute. Rather, the central concern is that spirituality already permeates the invisible social structures, shaping the illness experience, and forms clinicians into a spirituality of immanence. Statues are just the tip of the iceberg.

    We certainly agree with Dr. Mobin-Uddin’s caution in how easy it might be to coerce and alienate, and that it is a minefield moving from a secular to pluralistic medical structure. This is why we suggested three criteria in the development of new social structures aligned with tradition-specific spirituality: (1) incremental development, (2) rigorous scientific evaluation, and (3) scientific results accessible for public discussion and evaluation (see 278). Hostility to Hospitality provides several patient and clinician examples and possible directions in how tradition-specific structures can be incrementally tested and put into practice (279–88). While structural pluralism carries obvious dangers, those threats are appreciably minimized if our three criteria are followed. Alternatively, if we do not move toward the path of structural pluralism, then we guarantee continued coercion and alienation through the hegemony of immanent spirituality. While Dr. Mobin-Uddin expresses understandable concern how the Christus Consolator may alienate some patients, our view is that the more ominous problem is that within the absence of traditional spiritualities in American medicine, an immanent spirituality continues to coerce and alienate a large majority of patients facing life-threatening illness.

Response

In the Service of the Practice of Medicine

Social Contracts and Theological Anthropology

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?


  1. Carol R. Taylor, “Health Care and a Theological Anthropology,” in Health and Human Flourishing: Religion Medicine, and Moral Anthropology, ed. Carol R. Taylor and Roberto Dell’Oro (Georgetown University Press, 2006), 226.

  2. Justin M. List, “Clinical Issues and the Empirical Dimensions of the Religion and Health Connection,” Virtual Mentor 7.5 (2005) 367–70.

  • Michael and Tracy Balboni

    Reply

    Do Justice and Love Mercy

    Many thanks are due to Dr. List’s painstaking read of our book, and insightful comments. His question about the relationship of medicine as gift and medicine as a social contract is important and not easy to answer. The book left this issue undeveloped. Dr. List has far more experience and expertise to work out the implications. While the question falls too far outside our own fields for serious engagement, we can participate in a friendly conversation. The bottom line is that an approach that identifies “medicine as gift” overlaps with but also rebukes conservative and progressive social visions of medicine. Let’s consider a few strengths and weaknesses of both approaches.

    America’s free market approach to medicine has led to mixed results. The free market approach is grounded in the concept that medicine has value as measured by the valuation, typically in dollars, of the painstakingly-garnered expertise and technologies that comprise its craft. This commodified approach conceptualizes medicine as a value of exchange. Hence, to obtain access to medical expertise and/or technology requires an exchange of something of commensurate value. In this conceptualization of medicine, those who take financial and career risks in producing new health technologies, or those toiling to provide competent and compassionate medical care, are duly recognized for producing and administering medicine. Accordingly, a commodification approach to medicine is more likely to accelerate technological breakthroughs for healing, innovations partly driven by extrinsic ambitions. These therapies and health technologies enlarge the quality and potency of medicine. Medicine has amply grown into such a desirable and expensive commodity largely due to human ingenuity, ambition, risk, and financial reward. However, if market forces are medicine’s prime driving energy, commodification becomes a destructive social force undermining the persons it claims to serve. It leads to vast inequities in care and worse health outcomes among the poor and other vulnerable populations, undermining the intrinsic value of each person. Health care inequalities are mitigated, though hardly solved, by governmental programs to ensure adequate health care access, particularly for poor populations. But as the costs of health care continue to rapidly expand, the ability of governmental programs to bridge this gap is increasingly limited. Furthermore, the energies of a free market medicine can be propelled willy-nilly by our latest fads, subjective needs, and the waste of enormous resources for questionable technologies that fail to serve the public good. Commodification has resulted in unethical medical practices due to financial incentives, feeding endless, exorbitant greed. Medicine as commodity produces mixed results in that though it recognizes the value of medicine as craft, it often leads to the undermining of the intrinsic value of human person.

    The concept of medicine as human right is a counterbalance to medicine as conceived by the model of commodification. Human rights upholds the dignity of each person. Rights obligate the state and state actors to respect, protect, and fulfill policies and actions that lead to accessible and affordable health care. Access to health care is everyone’s due.1 Institutions and professions are responsible to maximize the availability of health and medicine, operating as stewards not proprietors. This suggests movement toward a universal system of health care. Too many do not have access to even modest levels of medical care, and this is at odds with the responsibility to steward medicine as a gift for all, not just those who can afford it.

    However, an appeal to health rights carries weaknesses that are important to also highlight. The two most prominent are as follows:

    One weakness is that it is hard to prove where health rights come from and why it is a moral obligation to provide them without a larger moral framework from which to stake that claim. While acknowledging arguments like John Rawls’ “veil of ignorance,” which attempts to establish human rights based in a common understanding of liberty and fairness, we are not persuaded that strong communities of justice generate these theories or are energized by them. The appeal to health rights, such as argued by the World Health Organization, intentionally avoids explaining the rationale for rights. Silence is preferred to clarification in order to hold together incommensurate rationales. This leads to a thin consensus, with the meaning of health rights and their justification deeply disputed. Competing claims of human health and justice are a reminder of Alasdair MacIntyre’s argument in Whose Justice? Which Rationality? One viewpoint argues, for example, that women’s reproductive rights demand reasonable access to abortion as a matter of justice. Contrastingly, others see abortion as an act of injustice against unborn persons. Michael Sandel concludes that “both positions presuppose some answer to the underlying moral and religious controversy.”2 There are many other health issues with incommensurable and competing claims of justice and conceptions of the human. Concepts of health rights are inseparable from cultural, and ultimately, metaphysical assumptions about what is a human, the ends of health, and applied justice. While rights advocates use similar language and agree on some health applications, irreconcilable disagreement lies hidden within this framework. Human rights language appropriates the benefits derived from religious worldviews demanding human dignity, but it conveniently disguises or ignores the metaphysical and theological presuppositions that generate these conclusions.

    A second dilemma to health rights is that there is little means to adjudicate between intrinsic health rights versus health commodities. A rights framework leads to the demanding of health care because of the intrinsic value of the person, but there are few principled ways to limit demand in light of the intrinsic worth of the person. How do we in principle differentiate health right claims to clean drinking water, free contraceptives, advanced fertility technologies, or future telomere technologies that slow aging? Differentiating a health right from a commodity requires deeper appeal to the human telos and a corresponding moral framework. If any or all of these are deemed intrinsic rights, availability comes down to resource allocation, but even resource allocation is driven by a culture’s deepest beliefs and values. So rights provide no principled way to differentiate what is justice and what best remains in the category of commodity.

    If “medicine as commodity” is on the x-axis and “medicine as right” is on the y-axis, then “medicine as gift” is akin to being on the z-axis. When medicine is framed within the concept of a divine gift, it places it within a larger moral framework of what it means to be human. As gift, it becomes linked to a larger worldview of human motivation, a system of morality, a theological anthropology that grounds human dignity, recognizing human finitude, and acknowledging the blessings and many limits of medical technology. Medicine as gift recognizes the benefits of approaching health as both a value and as a health right, yet critiques both. How so?

    Its rebuke of commodification is that the gift of medicine is given to all, rich and poor alike, and so all should have equal and affordable access to basic medical care. The core of medicine is not a commodity. Hence, this framework demands the administration of public health, preventative care, and a number of medical and palliative treatments, and surgeries. Affordable health care for all seems most congruent with the dignity of the human person made in the imago Dei.

    Its rebuke of health rights is that the gift of medicine requires a specific moral compass, a compass that provides the means to navigate between health right from commodity. The nature of the gift directs public health and medicine in relationship to the Gift Giver’s moral universe. In our view this leads to a tradition-specific religious or religious-like worldview operating in tandem with medicine. Without a larger moral framework, the justification of human dignity is meager, and there is no principled way to identify which medical therapies are a right and what are elective.

    As gift, a larger metaphysical narrative and moral framework serves as compass to differentiate a health right from commodity. Any shared nationalized system of health care would need to constrain health rights to where there is reasonably high moral consensus across most traditions. Apart from such an approach that acknowledges our moral pluralism, we are left with our current fraught circumstances: A tug-of-war between conceptualizing medicine as a human right versus commodity, with its adjudication exercised through sheer political power.


    1. https://apps.who.int/iris/bitstream/handle/10665/42526/9241545690.pdf;jsessionid=40AA80AA8F7F08666E8781EF9D5235C1?sequence=1.

    2. Michael Sandel, Justice: What’s the Right Thing to Do? (New York: Farrar, Straus and Giroux, 2009), 252.

Response

“Those Who Have No Desire for Redemption Have Everything for Sale”

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.


  1. Balboni, Hostility to Hospitality (New York: Oxford University Press, 2019), 1; subsequent citations to this work are parenthetical.

  2. T. D. Shanafelt et al., “Changes in Burnout and Satisfaction with Work-Life Balance in Physicians and the General US Working Population between 2011 and 2014,” Mayo Clinic Proceedings 90.12 (2015) 1600–1613.

  3. For a fuller account of this analogy please, see the biblical book of Exodus chapter 5.

  4. See his paper presented at the conference on “Christianity and the Flourishing of Universities” at Oxford, May 24–25: Miroslav Volf, “Life Worth Living: The Christian Faith and the Crisis of the Humanities,” Yale Center for Faith & Culture.

  5. Augustine, Tractates on the Gospel of John 10.6.1–3 (FC 78:216–17).

  • Michael and Tracy Balboni

    Reply

    In the Midst of the Gods He Holds Judgment

    Many thanks to Dr. Dugdale for her careful reading of Hostility to Hospitality, and for her thoughtful critique. She expresses some skepticism that structural pluralism holds enough weight to yield the results we discuss, such as addressing patient spirituality, mitigating clinician burnout, or resisting the impersonal social forces driving medicine further away from patient-centered care. Dr. Dugdale grounds her skepticism in the consumerism that has enfolded the practice of medicine. Consumerism is a major current within our culture driving the medical system. Clinicians cannot resist the direction of this current because it is either too mighty a stream, even if disliked, or because many clinicians have swallowed the economic system, often benefiting from the consumerist mentality awash throughout healthcare. Dr. Dugdale argues that before structural pluralism could plausibly accomplish change, there must first be “a desire for redemption.”

    We agree, and yet think the situation is more bleak than what consumerism alone accounts for. Consumerism is only one expression of the social forces undermining medicine’s capacity to provide patient-centered spiritual care. In addition to economic motivations, the book argues that there are two additional forces at play, the scientific-technological and the legal-bureaucratic (see 227ff.). As these three forces operate in tandem, the market-technological-bureaucratic powers decrease spiritual care, and increase impersonal, dehumanized medicine. A consumerist culture is only one dimension of the problem in need of redemption. The energy of these three interlocking forces drives medicine away from the personal and familial, and toward an economic system governed by maximum efficiency, calculable rules of output, specialization, and the elimination of decision-making bound within communal relationships. The underlying rationality led Max Weber to his well-known dystopian conclusion that our capitalistic system has become our iron cage. In other words, these impersonal forces are so entirely interlocking that they form a power relationship that is, in the words of Weber, “practically unshatterable” (230).

    What is unfortunate is that many people of good will, who perceive that something ails medicine, still rely upon the same impersonal measures and solutions in their attempts to address medicine’s dehumanizing tendencies. They put forward solutions that amount to more science, greater efficiency, more legal oversight, or financial tweaking. In the metaphor that Dr. Dugdale suggests, the slavery of Egypt has not only captured clinicians, but Egyptian rationality has worked its way deeply into medicine’s soul. This in no way cheapens the importance of science, nor suggests that health care can be effective without a well-run economic and bureaucratic system. Rather, what is lost is a patient-centered logic flowing from hospitality and compassion. When hospitality is the chief energy empowering the practice of medicine, then its partnership with technology, bureaucracy, and economics becomes a good and mighty river of life.

    Medicine has increasingly lost the logic, motivation, and institutions that flow from the practice of hospitality. A movement from hostility to hospitality invites a return to the one social energy able to shatter the iron cage of patient dehumanization, clinician burnout, and marginalization of spiritual care. This is an institutional or systems level problem, not an individual failure of compassion. Individuals (even highly influential ones) cannot overturn zwekrationale, technocratic, impersonal rational forces. Only equally powerful institutions, not under the powers of the economic system, have capacity to safeguard and further extend hospitality and compassion. While we live in a culture that cherishes the concept of compassion, there is a breakdown on the institutional level whereby few healthcare organizations can simultaneously nurture and sustain hospitality and then also meet the demands of technology, law, and economic viability. Other institutions are needed, but because religious institutions are either withdrawing or being forced out of healthcare (for financial or ideological reasons), the system is losing those institutions most able to champion and defend the social energies connected to hospitality.

    Structural pluralism is in part a proposal that addresses the loss of institutions who hold hospitality and compassion as their raison d’etra. Medicine cannot be left into the hands of only those institutions, which by their very purpose are driven by principles of impersonal rational forces. Depersonalization is an underlying assumption for the scientific endeavor, as it is in capitalism, and bureaucracy. Despite many good intentions, hospitals and professional guilds are caught within the gravitational pull away from person-centered care and toward impersonal rational forces. If hospitality is to remain at the heart of medicine, then there should be institutions that are as powerful and unyielding, to bring check-and-balance within the American system. Despite their foundational and historic role in medicine and health care in the United States, spiritual communities have been largely expunged from health care (see ch. 7, “The Secular-Sacred Divide in Medicine,” for our argument on this point). Structural pluralism is a proposal that speaks to the loss of traditional spiritual communities in medicine, and a possible way of reintroducing them into American medicine. We do not see structural pluralism as a panacea, but a pragmatic proposal that addresses secular and pluralistic concerns.

    We also concur with Dr. Dugdale that a necessary prerequisite for structural pluralism to work well is an “awakening of the need for redemption.” What will it take for clinicians and patients to hunger for this change? It is impossible to be certain, but we stand by our conclusion in the last pages of the book:

    What are the chances of such a cultural and professional turn away from problematic motivations caused by fear, money, ambition, or simply confusion that comes with lost vision? At the current moment, chances appear slim partly because there are so many hands in the money pot of medicine, the camouflaging of death remains a preeminent cultural power, and rival traditions too often trust in political means to adjudicate difference. Similarly, overwhelming social forces seem impenetrable and unstoppable. Even yet, repentance can include the most unexpected people and occur at the most surprising times.” (311)

    We continue to hold out hope that awakening of mind and heart is still possible.

  • Michael and Tracy Balboni

    Reply

    Not to us, O Lord, not to us

    We are grateful for Chaplain Klink’s analysis and delighted to further engage him as a hospital chaplain.

    First, one practical concern that Chaplain Klink touches on was the book’s failure to explain how religion affects a physician’s clinical reasoning in everyday medicine. A reasonably strong case can be made that a clinician’s spiritual tradition plays into (1) the physician’s approach to ethics, (2) the willingness to recognize and address patients’ spiritual needs, (3) the ability to recognize and sympathize with a patient or family who relies on religious rationales for medical decisions (e.g., receipt of more aggressive therapies in looking for a miracle), and (4) clinician spirituality having a protective effect against burnout and depersonalization. These are all fairly important domains in themselves, and we discuss them in the book.

    Nevertheless, rather than focusing our argument on clinician reasoning, the book looks at how patient religiousness and spirituality shapes the patient’s clinical reasoning in serious illness (chs. 2–3). The empirical evidence demonstrates that serious illness is a spiritual event for almost all patients in the United States. Therefore, clinicians must adapt to the patient as the center, not vice versa. Since most seriously ill patients clinically reason with religious rationales as an important component, clinicians should then be minimally knowledgeable of religion in order to better navigate it, and patient-clinician religious concordance should be considered as a potential factor in growing therapeutic alliance.

    Chaplain Klink’s statement that “treatment protocols are dictated by scientific reason not by faith” seems to perpetuate the polarization between medicine and religion, missing the underlying congruity that the book argues toward. We would not expect clinicians of different Christian denominations or religions to practice therapeutic protocols differently. This is not because Abrahamic religious reasoning is compartmentalized and non-overlapping from biomedical reasoning. Rather, there is a synergism of underlying assumptions concerning the nature of reality (see 179–82). There is a shared worldview about the nature of reality (e.g., the nature of instrumental causation), so that “scientific reasoning” and religious reasoning operate in tandem, almost indistinguishably. Moreover, clinical reasoning about treatment protocols cannot be separated from the moral framework of caring for persons. One might wrongly or foolishly think, “Just let the sick person die.” Why bother treating this patient? Scientific reasoning cannot give answer to this question but must operate in partnership with moral and spiritual rationales, which lead to compassionate action. Nearly identical deep assumptions between denominations and varied religions lead to similar clinical reasoning and practice. But identical assumptions should not be confused with mistaken views separating religion and medicine.

    Second, a theoretical concern Chaplain Klink raises focuses on the theological claim that medicine is a divine gift. He challenges this as a narrow, non-representative view of the classic Christian tradition. We stand by the book’s claim that monotheism, and classical Christianity in particular, affirm the axiom that medicine is a divine gift. In chapter 10 we highlight two seminal texts: the Jewish writing of Ben Sira (or deuterocanonical Ecclesiasticus 38) and Bishop Basil of Caesarea’s Long Rules 55. Ben Sira represents the acceptance of Hippocratic medicine in Second Temple Judaism and Basil serves as key to Christian acceptance of medicine in the Greco-Roman fourth century. Both specifically pay attention to medicine’s nature as a gift from God. This concept runs throughout most of the Christian tradition in discussions of medicine.

    In regards to Chaplain Klink’s quotation of Martin Luther, we suggest that it illustrates, rather than undermines, this axiom. In fact, the most eminent historian of medicine and religion, Gary Ferngren, discusses Luther’s thinking about medicine by noting that his view of “medicine was as much God’s gift as food and drink were.”1 Western faith communities accepted partnership with medicine because God’s healing powers could be received miraculously, without natural means, or mediated through secondary causes, themselves created by God as a gift.

    Throughout the classic Christian tradition, medicine has been generally interpreted under the category of providence. Classic formulations focused on divine providence2 describe a concurrence of divine and human agency. In the terms of Thomas Aquinas, God is the primary cause, and God works through secondary or mediated causes within creation. Christian providence is not a teaching of unilateral omnicausal divine determination that removes human agency. Mediated human goods derived through natural means and human actions are interpreted in the biblical tradition as still obtained from their Source, and thus, gratitude is to be expressed primarily to God (Isa 26:12). In this tradition, it is proper to give God thanks for our food (Ps 145:15–16), even though we work the land to produce it. Clothing is a human art and result of human labor, but the doctrine of providence concludes that it is God who ultimately provides our clothes (Matt 6:28–30). Likewise, human agency is a core belief driving the medical arts, as they require the arduous work of scientific study, wisdom of well-trained and experienced clinicians, and cooperation from willing patients. Nonetheless, human agency is not autonomous or unilateral, but operates concurrently with divine providence. Thus, when healing takes place, it is divine, rather than human agency, that receives ultimate credit. It is God who foresaw and created medicinal agents that could be used for healing. It is God who formed each human mind able to realize and apply science to its therapeutic effectiveness. It is the Lord who designed the human body so that it has capacity to heal and mend itself under the aid of the medical arts. God’s healing mercies cooperate in and through free-will human agents, so that when healing occurs in every instance, credit and gratitude are penultimately given to mankind, but ultimately and primarily offered to God. In the case of a gastro-intestinal surgery, the surgeon is part of the instrumental or secondary cause of the patient’s healing, but God is the ultimate or primary cause.

    At its most elementary level in medicine, the issue of providence is a concept that addresses who gets primary acknowledgment and credit for healing. A secular approach claims that the medical system should be neutral or silent in answering this question. Each person can make up his or her own mind. In contrast, the theological construct we attempted in part 2 of the book argues that when it comes to sickness and healing, the collective structures of medicine are not spiritually neutral. We argue that secular medicine rests upon flawed definitions of religion (ch. 9), fails to see its own theological anthropology (ch. 10), and that medicine’s institutions and professions function similarly to religious-like institutions in pre-secular societies (ch. 11). Likewise, when it comes to the genius of medicine, the collective assumption of secular medicine is that humanity, not God, ought to receive praise when healing takes place. The system de facto recognizes and celebrates human agency within healing. Reverend Klink offers us an example of Duke Medicine’s motto, “Where Miracles Happen.” Though it sloppily confuses providence and miracles, it is more than just a slick advertising slogan. Far more telling is its (along with many similar hospital mottos) willingness to appropriate religious-like language to itself; and just as importantly, neither clinicians nor patients appear too troubled by it. It is a subtle but relatively explicit boast that medicine’s healing energies are the product of human genius. The subtle and unspoken implication is that divine agency is unnecessary to acknowledge. Whereas the system makes certain that you acknowledge and give credit to human agency. This is not neutral.

    When put into its larger context of illness, fear, and dying, it comes too close to being religious-like to casually dismiss the slogan. The burden of our book aimed to explain why traditional spiritualities have been increasingly marginalized throughout medicine. Part of our conclusion is that the religious-like dynamics in medicine form their own spirituality of immanence. Immanence allows for the privatization of patient religion, but it will not tolerate traditional spiritualities operating on a structural level. This is why spiritual care of seriously ill patients is infrequently addressed by clinicians, and it is why religious leaders, including chaplains, remain profoundly marginalized.

     


    1. Gary Ferngren, Medicine and Religion: A Historical Introduction (Baltimore: John Hopkins University Press, 2014), 139.

    2. Here is a classical consensual Lutheran definition of providence: “Providence is the external action of the entire Trinity, whereby (a) they most efficaciously uphold the things created, both as an entirety and singly, both in species and in individuals; (b) concur in their actions and results; and (c) freely and wisely govern all things to their own glory and the welfare and safety of the universe, and especially of the godly.” H. Schmid, The Doctrinal Theology of the Evangelical Lutheran Church, Verified from the Original Sources, trans. C. A. Hay and H. E. Jacobs, 2nd English ed., revised according to the 6th German ed. (Philadelphia: Lutheran Publication Society, 1889), 182.

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