The Two Do Not Inhabit Separate Spheres, But Are Connected
Spirituality and healthcare belong together. After all, spirituality inspires and shapes the commitment of religious communities to found and sponsor institutions that care for the sick. Moreover, research has confirmed that the practice of spiritual disciplines can have a positive medical value and so must be regarded as a significant variable in the overall well-being of the patient. Holistic care is now the standard of care. That being so, everyone is getting interested in spirituality—from managers to medical professionals to patients. It is no longer the preserve of the spiritual care department. Spiritual interests and practices are cutting across the boundaries of religion and medicine to become integral to all aspects of the practice of medicine, including ethics.
However, the relation of spirituality and ethics in healthcare has not yet received much attention. While considerable effort has gone into developing and refining modes of ethical thinking to guide clinical practice, little effort has been directed toward making the connections between spirituality and ethics. This article attempts to make those connections.
To cut to the chase of relating spirituality and ethics, consider the following question: What aspect of your life do you most value? Pause here and make a mental note of, or write down on a piece of paper, that aspect of your life which is most important to you. How you answer this question reveals an aspect of your spirituality that will influence your decisions for treatment or not. I will come back to this question to show its influence on the application of spirituality and ethics in the practical realm of clinical decision making. My contention is that our spirituality is the wellspring of moral living. Ethics without spirituality is rootless; spirituality without ethics is disembodied.
Many people think ethics is about making decisions to do what is right and to avoid what is wrong. The process of making decisions often engages a common set of principles (in bioethics we speak of autonomy, beneficence, justice; in religion we speak of the Ten Commandments, the Great Commandment, and the Golden Rule). The process also often has an eye on avoiding harmful consequences and presumes the obligation and the duty to act according to principles. Public justification for a moral position is often given, then, in terms of the principles and consequences that determine the final decision.
But ethics is about more than interpreting principles and assessing consequences. Ethics is also interested in personal character—our stable identity, our deepest desires and ideals, our loyalties and commitments, our beliefs and attitudes, our motivation and perspective, our values and virtues. When we move from the decision making/act-centered interests of principles and consequences to the person-centered aspects of character, we are reaching into the inner dynamics of human action. These deep dimensions of the self are influenced by our spirituality.
Spirituality has to do with our relationship to what we ultimately value and with our commitment to live in a way consistent with what our ultimate love demands. To make spirituality the wellspring of morality, then, is to say that the person we become and the choices we make express what we ultimately love. Spirituality may name this ultimate love "God," or it may not. Christian spirituality does. It presupposes a commitment to live in relation to God, revealed in Jesus, as the source and end of all love, the One in whom everything else has meaning and worth. Thus, our spirituality shapes the perspective from which we see everything and by which we integrate the fragments of our life into a meaningful whole.
A way of living that is rooted in our spirituality is the dynamic expression of being in love with God. It begins with accepting that God loves us. The basic Christian kerygma is that God has first loved us and that accepting this love opens us to love all things in return. This means we assume responsibility for ourselves, others, and the world. What God's love for us does is analogous to what human love does. To know that someone loves us, that we are special to him or her, not only brings the beloved close to us but also strengthens, consoles, and empowers us to be our best selves and to care about what our beloved cares about. Spirituality can never be separated from the moral life as some external aid that helps us to be good, for spirituality is the awareness of being loved and the commitment to living in a way that makes this love a real, transforming presence in the world.
Spirituality and Ethics
The heart links spirituality and ethics. The language of principles and consequences that makes up our public ethical discourse is the product of cognitive reflection. Such reflection can be far removed from where our heart lies as the true expression of who we are and what we stand for. Clearer indicators of the heart come through expressions of feelings, intuitions, and somatic reactions. Ethics has for too long neglected these prereflective sources as being reliable guides to moral truth. But our spiritual tradition of discernment has relied on them as pathways for discovering what fits as true for the one making the decision.
Members of ethics committees may better understand how to account for impasses in their deliberations or moral disagreements by taking into account the link of spirituality and ethics. We disagree or come to an impasse, not because one of us favors principles and another looks to consequences, but because our hearts are not in the same place. Where we stand morally is primarily a matter of the heart. If our hearts are not in the same place, then we won't see the same things (that is, we have different perspectives) and we don't care about the same things, or we care about the same things but not to the same degree (that is, we differ in our desires, motivation, attitudes, and identity). We disagree morally because we differ in character. Perspective, motivation, beliefs, loyalties, and strong feelings are all aspects of our character. We disagree on moral matters ultimately because we disagree about what counts most in living. What counts most is a matter of our spirituality informing our ethics.
If, in discussing a clinical moral dilemma, someone is expressing strong feelings of anger or fear, we need to look behind those feelings to the deeper convictions that express what that person really cares about. This deeper caring is the inner dynamic that influences what one sees, what one values, and how one wants to act. The tradition of discernment reminds us that the murmurings of the heart are the messages of God. Moral living that arises from spiritual discernment is primarily a matter of following the heart. When we begin to touch what we ultimately love, what deeply motivates us, what gives us meaning and identity, then we are making the connection between spirituality and ethics. The spiritual connects with the ethical at the point of what counts most for us in living. That is why what you named above as an aspect of your life that you most cherish touches into your spirituality and will influence your moral vision, values, and choices.
Application to Clinical Practice
Now we are ready to make an application of this vision of the relation of spirituality and ethics to the practice of clinical ethics in healthcare. One of the decisions we often have to make is whether to treat or not to treat. The standard criteria used to determine whether to treat or not are expressed in two questions: From the perspective of the patient, does the proposed treatment offer a reasonable hope of benefit? and, Will the proposed treatment impose an excessive burden to the patient or family? (Ethical and Religious Directives for Catholic Health Care Services, directives 56, 57) How the patient weighs benefits and burdens reflects what the patient most values about life. So deciding whether to accept treatment or not is fundamentally a spiritual exercise yielding a practical judgment.
To get at the spiritual roots of this decision for yourself, retrieve what you named above as that aspect of your life which you do not want to lose. Your decision to treat or not will be based on whether the treatment will enable you to maintain or enhance your ability to appreciate that "love" of your life. If you are a proxy and have to make a decision for someone else, your interpretation of what that person is experiencing now or may experience as a result of further treatment will be influenced by what you most value about life. You will inevitably project your spiritual vision and commitment onto that other person and decide in light of it.
When I ask others what they most cherish in life, I get answers like my children, the freedom to speak what I think, control, my ability to have influence, being connected, my independence, my ability to care for others, my compassion for others, my friends, my ability to relate, a sense of humor. So, if your children are what you value most in your life, then you may want to undergo treatment that will buy time for your children to come and gather around you before you die. If relationships are what you value most, then you may want to forego treatment that will not restore consciousness.
The ministry of spiritual care can be a great help in this process of patients awakening to their deeper loves and longings before preparing advance directives or making decisions about treatment. While we all live with a deeper sense of purpose in life, we rarely take time to state it explicitly. Yet our cherished values function as an influence on who we are and what we choose. By listening to a patient's life story and identifying that patient's "value history," spiritual care ministers can help patients recognize and name their most cherished values that will influence any weighing of benefits and burdens that lead to a moral judgment about treatment.
Advance directives are generally written in the language of what we want or do not want in the event that we cannot speak for ourselves. But what lies behind those directives as the unexpressed limit is the deeper sense of what we most value about life and the kind of life that we believe follows from what we most cherish. Thus, the moral decision to refuse treatment or to undergo treatment cannot be separated from one's spirituality, from one's deepest longing for what makes life ultimately meaningful.
Joining Ethics and Spirituality
If spirituality is going to be integrated into all aspects of healthcare, then we must include its relation to ethics as well. Spirituality and ethics cannot remain two separate spheres. Spirituality cannot be restricted to the inspiration of a religious community to engage in the ministry of caring for the sick, nor can it remain the practice of prayer and sacramental rituals. Spirituality encompasses the whole of life lived in relation to God as our absolute value. As such, spirituality influences our outlook on life and it supports our moral character and the style of life that grows out of our commitment to God.
Ethics cannot be reduced to or restricted to decision making and the justifications we give to support what we do. Our ability to identify a problem, and even to solve it, is not just a moral skill but it is also a measure of our spirituality. To the extent that ethics is concerned with the inner dynamics of personal action, then to that extent we can say that ethics is rooted in our spirituality and our spirituality embodies our ethics by expressing a style of life that is grounded in our love for God and God's love of us.
Fr. Gula is professor of moral theology, Franciscan School of Theology, Graduate Theological Union, Berkeley, CA
Copyright © 2000 by the Catholic Health Association of the United States
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