AMA Journal of Ethics^®

Some have expressed the hope that the recent increased interest in spirituality and health would offer new and creative opportunities for the practice of medicine. While this vision is alluring, the conversation to date has frequently reflected a spirituality that is used as one more tool to fulfill the consumerist expectations of our current therapeutic culture. Rather than offering a distinctive voice for reforming our practices of caring within health care, the prevalence of this therapeutic adaptation of spirituality has distorted and limited the potential contribution of the spirituality and health movement within the practice of American medicine.

The illusion of our therapeutic culture—that the obsessive pursuit of cure and self-enhancement is always an unambiguous good—too often frames our understanding of spirituality and its role in health. Spirituality becomes a means to the end of an individualistic sense of well-being and health, an end to which the contemporary health care consumer presumes to be entitled. This understanding of a therapeutic spirituality increasingly has become detached from religious practices and communities of faith. Spirituality is understood as an individualized expression of desire and expectation to be fulfilled through a contractual exchange with God or whatever the object of one's spiritual inclinations might be. The deal that is implied within this exchange reduces both spirituality and health to commodities. This reductionism distorts our traditional theological understandings of prayer and worship within spirituality as well as our understanding of medicine as a practice of service. In Heal Thyself: Spirituality, Medicine and the Distortion of Christianity, Shuman and I commented, "If the human relation to God is essentially contractualthat is, technical and instrumental then God becomes obligated to fulfill the contract providing health in exchange for devotion…. Improvements in the health of persons notwithstanding, something is lost when the interrelationship of faithfulness and healthfulness is reduced to exchange."¹ The notion of covenant as a basis for interpreting relationships in both spirituality and medicine is lost when contractual exchange becomes the prevailing paradigm. Entitlement, rather than gratitude, becomes our framework for expressing and interpreting both spirituality and health. This presumption of entitlement within a commodified understanding of spirituality and health limits the potential for gratitude in forming both the human spirit and our understanding of transcendent spirituality.

Utilizing spirituality as a therapeutic technique also contributes to the excessive expectations of patients who frequently ask medicine to provide unmitigated cure and self-enhancement. Interjecting God, or whatever spiritual surrogate for God the patient may choose, into the formula as a therapeutic intervention for negotiating their expectations potentially already inflated expectations sets up both the patient and the clinical providers for distrust and disillusionment. This understanding of spirituality misguides patients and physicians leading to distortion and confusion regarding the relationship of spirituality and health. While therapeutic uses of spirituality are most likely well-intended when attempted by practitioners, they can divert us from a more vital and theologically cogent appropriation of spirituality within health care. We lose sight of the more substantive offerings of a community of practice and caring formed in particular practices of caring that reflect a serious engagement of medicine with the spirituality of patients. Without presuming to use spirituality as some therapeutic technique, attentiveness to spirituality can help interpret and re-narrate illness, so we can see more clearly how our patients might flourish and to what ends we provide care in spite of the suffering and illness common to us all. The inevitability and mutuality of suffering as part of human existence is something we try to deny through the lens of "technological utopianism" as part of our therapeutic culture.² Spirituality in health care should offer an antidote to this illusion rather than propagate its presumptuous implications. Rather than seeing spirituality's relationship to medicine as a therapeutic tool or technique, perhaps we might envision it as an alternative lens, one through which we can see and interpret the hopes and expectations of those for whom we care, regarding human flourishing in relation to God.

Crucial to gaining more clarity regarding spirituality and health in both research and practice is a more careful consideration of what we mean by "spirituality" and by "health." In concert with our need to reconsider the depths of our captivity to a therapeutic utopianism, Wendell Berry challenges us regarding the individualism of our understanding of health. He comments, "Health is not just a sense of completeness in ourselves but also is the sense of belonging to others and to our place; it is an unconscious awareness of community, of having in common."³ Berry will not allow us to reduce health to a private, individualized sense of well-being and contentment while ignoring the sustenance and care of the communities surrounding us and our patients. While challenging our definition of health in this context, we also need to consider a problematic conflation that occurs consistently regarding spirituality. In both research and practice the language of "spirituality" is used interchangeably between dimensions of the human spirit that might most accurately be described as psychological or existential and a notion of spirituality connoting some relationship to God or some clear sense of self-transcendence. Even though this use of spirituality may be common in our current cultural milieu, it does not contribute to clarity or rigor in either research or practice within the spirituality and health conversation.

As we seek to refine this conversation in order to improve the quality of our research and better serve our patients, the challenges are considerable. A pivotal contingency is the clarity with which we persevere in questioning the presumptions of our therapeutic culture and strive to formulate a true prophetic voice within the conversation about spirituality and health. The outcome may very well determine whether the spirituality and health movement of the last decade or so becomes a blip on the trajectory of American medicine or a force for transforming the practices of caring in American medicine.