Spirituality and Healthcare—Common Grounds for the Secular and Religious Worlds and Its Clinical Implications

Abstract

The spiritual dimension of patients has progressively gained more relevance in healthcare in the last decades. However, the term “spiritual” is an open, fluid concept and, for health purposes, no definition of spirituality is universally accepted. Health professionals and researchers have the challenge to cover the entire spectrum of the spiritual level in their practice. This is particularly difficult because most healthcare courses do not prepare their graduates in this field. They also need to face acts of prejudice by their peers or their managers. Here, the authors aim to clarify some common grounds between secular and religious worlds in the realm of spirituality and healthcare. This is a conceptual manuscript based on the available scientific literature and on the authors’ experience. The text explores the secular and religious intersection involving spirituality and healthcare, together with the common ground shared by the two fields, and consequent clinical implications. Summarisations presented here can be a didactic beginning for practitioners or scholars involved in health or behavioural sciences. The authors think this construct can favour accepting the patient’s spiritual dimension importance by healthcare professionals, treatment institutes, and government policies.

1. Introduction

The concepts applied in healthcare sciences are transient, and they are periodically reviewed. From the earliest times, healthcare and spirituality were closely linked, when spiritual leaders were commonly responsible for healing practices (Schumann et al. 2011). In the last few decades, the humanisation of medicine have been accompanied by the inclusion of new values, such as the appreciation of the person’s subjective experience, patient empowerment on treatment decisions, and a closer clinician-patient relationship (Hirpa et al. 2020). Comprehensive healthcare must now address the patient’s entire relational existence, in a real bio-psycho-social-spiritual model (Dhar et al. 2013). As a part of this process, the spiritual dimension of patients has gained progressively more relevance in healthcare. Currently, the spirituality of the patient is of paramount importance for high standard medical training and clinical practice (Isaac et al. 2016).

However, the term “spiritual” remains an open and fluid concept. It can refer to a host of different aspects, from non-religious and non-theistic levels (such as the power of positive thinking) to deeply religious experiences (such as a possession trance) (Saad et al. 2017). Contemporary, pluralistic society and individualistic culture allow different people to interpret diversely the term “spiritual”. Many people express their spirituality through formal religions or belief systems, while others strengthen their spiritual dimension with non-religious elements (Jiràsek 2013).

According to McSherry and Cash (2004), no definition of spirituality in healthcare is universally accepted, and the theoretical probability of arriving to such a definition is virtually zero. These authors acknowledge the diverse taxonomies that individuals may identify with and adopt. Because there are so many definitions, they state that spirituality can imply diverse things depending upon an individual’s interpretation or worldview. One’s cultural background may determine whether this attitude will take the form of a religious or a secular interpretation.

In health sciences, spirituality is an abstract and subjective matter, and it has more than 13 conceptual components (Paul Victor and Treschuk 2020). Moreover, some concepts of spirituality may work well in the clinical practice, but badly for research purposes (King and Koenig 2009). This inconsistency has led some authors (Reinert and Koenig 2013) to propose defining spirituality in the context of religious involvement when conducting research, while using a broader definition when providing spiritual care. Below are some examples of definitions for spirituality by some leading researchers:

• The personal quest for understanding answers to ultimate questions about life, meaning, and the relationship to the sacred or transcendent (King and Koenig 2009).
• The ways in which a person habitually conducts their life in relationship to the question of transcendence (Sulmasy 2009).
• A dynamic and intrinsic aspect of humanity, through which persons seek ultimate meaning, purpose, and transcendence, and experience relationship to self, family, others, community, society, nature, and the significant or sacred (Puchalski et al. 2014).
• A search for meaning, purpose, and transcendence and a connection to the significant or sacred (Sajja and Puchalski 2018).

Embedded in the above definitions of spirituality, one can find some common patterns: meaning, purpose, connection, transcendence, values, humanism, and universality.

The religious-spiritual wellbeing can be broadly defined as the ability to experience and integrate meaning and purpose in existence through connectedness with self, others, or a power greater than oneself (Unterrainer et al. 2010). This concept has developed to expand the bio-psycho-social model with a spiritual component, and it may be particularly useful in healthcare settings. In clinical practice, the degree to which patients’ spirituality can help them to cope with illness can shape their treatment planning (Bredle et al. 2011).

More recently still, the spirituality of the patient (either religious or secular) has become a focus item of interest for health sciences, particularly healthcare. Treating a human being calls for a combination of science and art, and is, therefore, rooted in both biology and humanities (Skinner and Rosenberg 2018). Medicine has been considered a science and an art, with both facets complementing each other (Herman 2001; Panda 2006). Commonly, only the science (facts, evidence), not the art (values, ethics) of medicine is seen worthy of academic study (Toon 2012). Thus, understanding the relationship between health sciences and religious values is crucial to fully comprehending the role of spirituality in healthcare.

The term secular spirituality is a relatively new concept, as spirituality was classically always related to religion. The term secular spirituality arose out of the need for scientific acceptance of spiritual experiences in a non-religious context (Walach 2017). A secular form of spirituality may have a strong relationship with mental health, as well as religious forms of spirituality (Moore 2017). The secularisation of society does not remove existential, spiritual, and religious needs, which are fundamental aspects of human being and suffering (Hvidt and Hvidt 2019). ‘Spiritual but not religious’ is an increasingly popular religious affiliation self-designation, although they form a heterogeneous population (Wixwat and Saucier 2020).

Vigorous debate continues over whether and how medicine and spirituality should be integrated (Balboni et al. 2014). As a relatively recent topic, spirituality in health has weaknesses and vulnerabilities open to ignorance and prejudice. In this process, some contradictions seem to hinder the development of this field and its effective implementation in practice. A few examples:

• In a study involving medical schools in Brazil (Lucchetti et al. 2012), 54% of the directors or deans believed that spirituality should be taught to students (still deemed low); however, only 10% of all schools surveyed had dedicated courses.
• Although the practice of medicine requires a secular facade, an extensive study in the United States (Curlin et al. 2005) revealed that 55% of physicians declared their religious beliefs to clearly influence their clinical practice.
• Biofield healing (a secular counterpart of spiritual healing) fits well in the integrative model of healthcare, satisfying the desires of many patients; however, it remains outside the conventional framework, mainly because of its conceptual bases (Hufford et al. 2015).
• Spiritual experiences have important effects on biological, cognitive, and psychosocial domains; however, their role in the clinical setting has generated considerable discussion within the medical community (Giordano and Engebretson 2006).

In this scenario, the present paper aims to clarify some common grounds between the secular and religious intersection regarding spirituality and healthcare, together with the consequent clinical implications. This is a conceptual manuscript based on the available scientific literature and the authors’ experience. The elements brought up in this manuscript came from the first author’s experience after 20 years of exploring the concept of spirituality in health sciences. Note that this is the personal conception of the authors, and therefore, it may contain opportunities for improvement. The authors believe this construct can favour the recognition of the importance of the patient’s spiritual dimension by healthcare professionals, treatment institutes, and government policies.

2. Secular and Religious Intersection Concerning Spirituality and Healthcare

The expressions spiritual wellbeing, spiritual coping, spiritual support, spiritual therapies, and spiritual phenomena are explored below. These expressions are listed in this order because they are progressive in nature, as illustrated in Figure 1. Spiritual wellbeing is related to health and quality of life, an association well accepted by health sciences. During a disease, this wellbeing is partially determined by spiritual coping, the use of spiritual resources to face the adversity. If the coping style of a patient creates spiritual struggle (tensions, conflicts, and concerns about transcendental matters), spiritual support may serve to modulate this suffering. Such support must encompass the entire belief system of the patient, which, in some cases, encompasses some form of spiritual therapy. This approach paves the way for the study about clinical impacts of anomalous spiritual experiences.

For each of these spiritual expressions, the ensuing text describes the concept, some secular and religious examples, the common ground for both, and some clinical implications. At the end of this discussion,

Table 1. Summary of each spiritual expression with its concept, some secular and religious examples, common ground for both, and some clinical implications.

Expression	Secular Examples	Religious Examples	Common Ground for Both	Clinical Implications
Spiritual wellbeing	Positive thinking and psycho-neuro-immune-endocrine pathways	“your faith has healed you” (Mark 5:34 and other biblical excerpts)	Faith affects physiology, independently of metaphysical issues	Respect spiritual values and be attentive to patient’s feelings and beliefs
Spiritual Coping	Support from rationalistic and humanistic worldviews	Prayer, sacred rituals, religious symbols, and faith community	Restore individual or cultural values to face an adverse experience	Know about negative coping, which affects treatment and worsens stress
Spiritual Support	Discussions on non-religious beliefs related to meaning and purpose.	Religious minister offering doctrinal counselling and sacraments	Spiritual needs are distinct from emotional and social needs, despite their interrelationship	Healthcare institutions should address questions regarding the spiritual dimension
Spiritual Therapies	Procedures centred on the vital bioenergy: Yoga, Reiki, etc., including meditation	Procedures centred on the potentialities of the soul: blessings, intercessory prayer, etc.	Activation of inner hidden resources through a facilitator	Accompany patients in their aspirations and desires with sympathy and respect
Spiritual phenomena	Scientific reports: memories of past lives, near-death experience, and end-of-life experiences	Mystical states: ecstatic enlightenment, possession trance, mediumship, and prophesy	Acknowledgement of the complexity of consciousness expressions	Accommodate patients’ values, while checking for mental illness

will summarise all the information presented.

2.1. Spiritual Wellbeing

• Concept: a state of positive feelings, behaviours, and cognitions that provides the individual with a sense of identity, wholeness, satisfaction, joy, contentment, beauty, love, respect, constructive attitudes, inner peace and harmony, and purpose and direction in life (Gomez and Fisher 2003).
• Secular examples: positive thinking activating psycho-neuro-immune-endocrine pathways and balancing neurovegetative functions through modulation of stress (Saad and de Medeiros 2017).
• Religious examples: “your faith has healed you” (some biblical excerpts such as Mark 5:34); “a cheerful heart is good medicine, but a crushed spirit dries up the bones” (Proverbs 17:22); “[to fear the LORD and shun evil] will bring health to your body” (Proverbs 3:8).
• Common ground for both: independently of metaphysical issues, a positive and causal association exists between faith and positive parameters of physical and mental health, including longevity (Saad et al. 2019).
• Clinical implications: Healthcare staff should respect spiritual values and be attentive to the patient’s needs and beliefs related to the disease experience.

2.2. Spiritual Coping

• Concept: the cognitive and behavioural efforts to find or maintain meaning, purpose, and connectedness in the face of threatening or distressing situations (Clark and Hunter 2019). In other words, the faith-related attitudes used to deal with a crisis, or to modulate the resulting emotional distress.
• Secular examples: support from rationalistic and humanistic worldviews, liberal values, and analytic thinking for a meaningful and healthy life (Uzarevic and Coleman 2020).
• Religious examples: strength from prayer, sacred rituals, and religious symbols. Religious leaders, organisations, and communities are a primary source of support, comfort, guidance, and direct healthcare (WHO 2020).
• Common ground for both: the importance of restoring individual or cultural values to face an adverse experience.
• Clinical implications: healthcare professionals need to know about negative spiritual coping (anger, sorrow, guilt, stigma, struggle), which adversely affects the course of treatment by worsening stress. If needed, secular spiritual resources can be used.

2.3. Spiritual Support

• Concept: giving professional attention to the subjective spiritual and religious worlds of patients, concerning the relationship of the sacred to their illness, hospitalisation, and recovery or possible death (VandeCreek 2010).
• Secular examples: atheists and agnostics may need to discuss non-religious beliefs and questions about meaning and purpose, such as thinking about one’s legacy and life review (Crane 2017; Thiel and Robinson 2015).
• Religious examples: religious minister offering doctrinal counselling and sacraments in hospital, such as anointing of the sick for a Catholic patient near death.
• Common ground for both: spiritual needs are distinct from emotional and social ones, despite the interrelationship among them. Therefore, they are outside the range of psychological interventions.
• Clinical implications: spiritual support should be considered essential care; healthcare institutions should address questions regarding the spiritual dimension and they should have clear policies to foster resource aids (Hall 2020). For hospital quality accreditation, the Joint Commission International questions in its Standard PFR.1.2 claims: The hospital provides care that is respectful of the patient’s personal values and beliefs and responds to requests related to spiritual and religious beliefs1.

2.4. Spiritual Therapies

• Concept: mystical, religious, or spiritual practices performed for the benefit of health, as defined in the Medical Subject Headings2.
• Secular examples: procedures centred on the concept of a vital bioenergy, such as Yoga, Reiki, Qi Gong, and Johrei. This includes meditation (even if this practice has religious roots).
• Religious examples: procedures centred on the soul potentialities, such as blessings from various traditions and intercessory prayer.
• Common ground for both: the activation of inner hidden resources through a facilitator (the practitioner), regardless of the mechanisms of action that explain their effects.
• Clinical implications: despite the lack of uniformity on physiological responses and low clinical relevance of effects, a humanistic, comprehensive, and integrative healthcare approach should accompany patients in their aspirations and desires with sympathy and respect. Thus, healthcare providers should define their stance regarding the validity and utility of these approaches, as patients will inquire about them (Rindfleisch 2018).

2.5. Spiritual Phenomena

• Concept: unusual experiences that deviate from the generally accepted explanations of reality, the so-called parapsychological (psi) phenomena (Cardeña 2018).
• Secular examples: scientific reports on memories of alleged past lives, with many cases of a match, near-death experiences with elements not related to hallucination, and end-of-life experiences with the embarrassing terminal lucidity (Daher et al. 2017).
• Religious examples: mystical states, such as ecstatic enlightenment, possession trance, prophesy, and mediumship (after-death communication).
• Common ground for both: the acknowledgement of the consciousness expressions complexity and the attempt to gain a deeper understanding of human condition.
• Clinical implications: clinicians should accommodate patients’ specific desires and needs related to spiritual experiences, as the outcomes may be potentially health promoting (Giordano and Engebretson 2006). However, the practitioner must check if a strange behaviour is benign or pathological, through the differentiation between healthy spiritual experiences and mental disorders with religious content (Moreira-Almeida 2013).

3. Discussion

The interest in connecting religious activity with healthcare has a long history of inquiry, but it has attracted academic concern only recently. The field of spirituality and health is growing rapidly, and it is moving from the periphery into the mainstream of healthcare (Koenig 2012). However, because the question of a link between religion and healthcare is still controversial, the discussion must continue, crossing disciplinary and specialty lines (Sloan et al. 2000). Every new field in science, especially in health, undergoes a probationary period during which it may come under attack from defenders of old ideas (Dyson 2012). With dialogue based on goodwill, it can be argued that religions and health sciences have different but complementary roles in healthcare.

Religions can learn from secularism in that some so-called miraculous healings may come from natural physiological pathways. Secularism can learn from religions in that many patients use their beliefs to frame health, disease, treatment, and healing (Levin 2018). The first step towards a fruitful coexistence between the religious and the secular in healthcare is achieving mutual understanding; the next is discern how to respect other systems while disagreeing (Crane 2017). Since the 1970s, the bio-psycho-social model has been a humanistic and holistic view of the human being. Currently, many researchers feel the bio-psycho-social model should be expanded to include the spiritual dimension as well (Powers 2016). Health sciences cannot exhaust the transcendent and sacred questionings only on the mental and social grounds. A true paradigm shift will take place only when the human spiritual dimension is fully understood and incorporated into healthcare.

4. Implication and Limitations of the Present Rationalisation

Health professionals and researchers have the challenge to cover the entire spectrum of the spiritual level in their practice. This is particularly difficult because most healthcare courses do not prepare their graduates in this field. They also need to face acts of prejudice by their peers or their managers. During these times of the COVID-19 pandemic, the role of spirituality in healthcare reaches an even greater importance. Koenig (2020) provided some recommendations to help the maintenance of spiritual, mental, and physical resilience. He points out that many scientific studies have reported an association between religious activity and better immune patterns. Therefore, he argues that staying spiritually healthy will enhance physical health and resistance to infection. This conclusion is corroborated by Levin (2020), who also values faith cultivation for its effects on physiology, especially on the immune system.

The summarisations presented here can be a didactic beginning for practitioners or scholars involved in health or behavioural sciences. We do not intend this text to be a contribution to the philosophical, anthropological, or religious concepts of spirituality. The authors acknowledge they oversimplified the reasoning, which may lead to the impression of argumentation based on presumptions, postulations, and assumptions. As a conclusion, here are a few short guiding messages, addressed to two different audiences of clinicians:

• A secular hint to religiously-oriented professionals: you can hold your faith to get the strength to face the professional challenges, but keep in mind that, most of the time, clinical practice demands physicalist premises and reductionist methods; you can always follow your personal commitments by referring the patient to another colleague in sensitive cases, such as abortion or euthanasia.
• A religious hint to secularly-oriented professionals: although some religious interpretations can be harmful to healthcare, our role is to give the patients the best information and allow them to decide; the acknowledgement of religious values of a patient is a very important ingredient of cultural sensitivity, and the respect for such needs is key for a patient-centred approach.