Oct 2009

Physicians and Patients’ Spirituality: Ethical Concerns and Boundaries in Spirituality and Health

Christina M. Puchalski, MD, MS
Virtual Mentor. 2009;11(10):804-815. doi: 10.1001/virtualmentor.2009.11.10.oped1-0910.


Spirituality has become an increasingly prevalent topic in current models of health care. More than 75 percent of medical schools teach topics related to spirituality and health, and hospitals are beginning to develop spirituality programs to increase the delivery of compassionate care [1, 2]. Spirituality can be defined as “the aspect of humanity that refers to the way individuals seek and express meaning and purpose, and the way they experience their connectedness to the moment, to self, to others, to nature and to the significant or sacred” [3]. Illness can trigger profound existential questions for the patient and family, as well as for health care professionals, and questions about why people suffer, die, or have to deal with unbearable stress are often at the heart of the clinical encounter.

Spirituality and religious beliefs and practices have been shown to have an impact on how people cope with serious illness and life stresses [4, 5]. Spirituality often gives people a sense of well-being, improves quality of life, and provides social support [6, 7]. Spiritual beliefs can also affect health care decision making [8]. Numerous surveys indicate that patients want their clinicians to talk with them about their spiritual needs and integrate spirituality into their treatment plans [9, 10].

Healing Clinical Relationships

An integral part of spiritual care is the focus on the patient-clinician relationship in which care is viewed from a humanistic as well as technical perspective. Differentiation is drawn between cure and healing and between disease and illness. An emphasis on cure or disease relies primarily on the scientific model of care. Focusing on healing or illness brings the patient and the physician into the clinical context. The patient’s wishes, beliefs, and values play a role in decision making and in the treatment plan. And the clinician’s ability to form a compassionate relationship with the patient is as important as that clinician’s ability to diagnose and treat the patient scientifically. Central to this healing relationship is recognition of and attention to the support that is available to patients in the midst of their illness. Studies have shown that ability to support patients in their suffering requires health care professionals to know how to be a compassionate presence, convey dignity, and attend to spiritual needs of families [11]. If they are to be fully present to the patient, health care professionals must prepare through reflection on their own sense of transcendence, meaning, purpose, call to service, and connectedness to others.

The focus on relationship-centered care implies that both parties are equal partners in the clinical healing relationship. Conversations about existential and spiritual issues transform the clinical encounter and its participants, as the clinician and patient move into a nontechnical and personal domain of experience. Clinicians have to recognize that they have the capacity to be deeply influenced by their patients just as they (clinicians) influence patients. There is an intimacy in these healing relationships and in spiritual care—one that must be engaged in with formality. Ethical guidelines are of paramount importance in relationship-centered care where boundaries are not explicitly clear [12].

Intimacy with Formality

Intimacy with formality recognizes that there is a power differential between the clinician and the patient. Patients feel a sense of vulnerability and lack of control and view the power and control as belonging to the clinician. Clinicians have a moral obligation to never exploit a patient, to be trustworthy, and to use their expertise and power with the best interests of their patients in mind. Conversations about spiritual and existential issues are deeply personal. In this context, the clinician must recognize that she is not an expert in the patient’s spiritual beliefs. Therefore, it is best to follow the patient’s lead in these conversations. Proselytizing by clinicians or dismissing patients’ spiritual or religious beliefs is unethical under all circumstances within the clinical encounter. Forcing a patient to share his or her beliefs or values is also discouraged, and patients’ privacy must be respected. Questions should be asked in a manner that conveys openness to all types of beliefs—humanistic, religious, and nonreligious alike. Some patients may have had traumatic experiences with religious or spiritual organizations and may be resistant to disclosing their backgrounds. Thus, a spiritual history or assessment should be sensitive enough to identify concerns in all patients and ask general questions that invite them to share what is important to them and their care [13-15].

Respect, patient-centeredness, and inclusivity are key ethical guidelines for medical practice [16, 17]. Respect means valuing the patient’s views even when they differ from more frequently encountered belief systems. Respect also extends to the recognition that individuals are unique—two people with the same religious affiliation do not necessarily treat all dogma of that religion in the same way [18, 19].


Appropriate therapeutic relationships with patients and families adhere to boundaries. This is for the benefit of the patient, family, and clinician. Boundaries are mutually understood, unspoken, physical, emotional, social, and spiritual limits to the professional relationship. Where the clinician ends, the other person begins. Observing boundaries shows a healthy recognition of the purpose of the relationship and, at the same time, avoids building walls. Boundaries allow clinicians to be in the present and to passively enable emotional, physical, or social distractions to flow freely, not interrupting the patient-clinician interaction. Suppose, for example, the patient verbalizes thoughts that for some reason make the clinician uncomfortable. Recognizing the professional boundary allows the physician to focus on the clinical issue rather than on the patient’s potentially distracting words or emotions, so the encounter can continue. Distancing, which many clinicians use to protect themselves, is based on a fear of entanglement and actually jeopardizes the clinical relationship in that it breaks the potential for a compassionate connection. Respect for boundaries, on the other hand, allows for compassionate presence in the healing encounter. Clinicians are more vulnerable to crossing boundaries when they are overworked, stressed, or have experienced losses or grief, so it is essential that they have avenues for self-care and reflection.


Spiritual care supports the relationship-centered model of health care. Clinicians who open the door to spiritual questions of meaning and purpose, suffering, and issues at the boundaries of life and death gain intimate relationships within the clinical context. To sustain this relationship effectively, ethical guidelines must be honored and boundaries observed for the sake of both patient and clinician.


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Editor's Note

In this series of op-ed articles, three authors explore a range of perspectives on the question of whether physicians should engage patients on the topic of spirituality.


Virtual Mentor. 2009;11(10):804-815.



The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA.