Recognizing Spiritual Distress

   The literature has long established that chronically ill people are likely to suffer emotionally as well as physically. To date, little has been discovered about the concept of spiritual suffering or, more specifically, spiritual distress. However, studies have suggested that attending regular religious services may lead to a longer, healthier life.¹ Only recently has spiritual distress been thought to shorten the lives of certain categories of patients. A new 2-year study of elderly hospitalized patients found that spiritual struggles, such as feeling abandoned by God, increased the risk of dying by 28%.²

   This article examines the patient-professional relationship within the framework of virtue ethics and spiritual distress.

Spiritual Distress

   A number of studies support the link between regularly attending worship services and longevity. A meta-analysis of studies totaling nearly 126,000 subjects found that participating in public religious practices like regular attendance at worship services increased the odds of living longer by 43%.³ For instance, African American worshippers who attended religious services more than once a week lived up to 14 years longer than those who did not.¹ However, individuals who experienced what the authors describe as spiritual distress actually died sooner.

   Pargament et al² conducted a study of nearly 600 patients, all of which were at least 55 years old. The subjects were matched for physical health, cognitive ability, mental health status, physical functioning, and demographic factors such as age, education, race and ethnicity, and gender. This 2-year study found that spiritual struggles significantly increased the risk of dying earlier. Patients who reported that they felt abandoned or unloved by the divine often attributed their disease to the work of the devil and were likely to die sooner.

Professional Relationships and Virtue

   Health and healthcare decisions of a moral nature are largely made from ethical rules, principles, and obligations. The Georgetown Mantra, for example, is based on the notion of ethics, which is derived from Kantian or utilitarian ethics. Aristotle and Plato ascribe more closely to what is described as virtue ethics. Although rules, principles, and obligations are important to many healthcare decisions, virtue ethicists would argue that even if a good moral decision is made, it must be made from the context of virtue. For example, a morally good clinician with the right desires and motives is more likely than others to understand what should be done, more likely to attentively perform the acts that are required, and even more likely to form and act on moral ideals. Therefore, a virtuous clinician is one who has the motivation and the desire to perform right actions, not necessarily as the rule follower, but as someone who is generous, caring, compassionate, sympathetic, or fair.

Case Study

   Rose was a 57-year-old woman with end-stage ovarian cancer. Like many patients with this condition, she developed a recto-vaginal fistula that was relatively well managed. She seemed to tolerate chemotherapy, radiation, subsequent hair loss, nausea, and the plethora of other distractions quite valiantly. Her faith in the divine had given her intense strength during her 5-year battle with cancer. Imagine her young physician's surprise when she found Rose sobbing uncontrollably one morning. Rose explained that she now more fully understood the reason why she had been afflicted with this cancer. She said it had to do with a young man she met when she was 19 years old. She was betrothed to another young man whom she eventually married; however, Rose believed that one afternoon of unrestrained passion was at the heart of her condition today. Rose explained that she felt God was punishing her for this act that occurred so long ago. "Why else would I have developed the fistula?" she asked. Her sense of abandonment was overwhelming. Her story was distressing to the physician. Of all the things to have to worry about at the end of one's life, feeling unloved and isolated from the power that had once provided such strength could prove the most devastating.

   Despite her heavy caseload and many other obligations, Rose's physician talked with Rose about her concerns. She arranged for a chaplain to come and discuss the situation in confidence. The physician expressed compassion in her intervention with Rose because the physician understood the serious nature of what she regarded as a devastating misunderstanding of divine power.

Discussion

   Today's clinicians can be overwhelmed with demands on their time, yet the physician in this case understood the depths of Rose's despair. Virtues in practice are described as habituated character traits that dispose persons to act in accordance with the worthy goals and role expectations of healthcare. Rose's physician, as a virtuous clinician, acted in a manner where compassion was the priority in her intervention.

   The virtue of compassion is a trait that combines an attitude of active regard for another's welfare with an awareness and emotional response of empathy, tenderness, and discomfort toward another person's misfortune or suffering. Compassion outwardly focuses on another person. The outward nature of compassion is important; clinicians who express little or no emotion in their behavior, but who demonstrated only expert clinical skill, often fail to provide what the patient really needs.

   Some authors argue that compassion may cloud judgment and preclude rational or appropriate responses. Savvy clinicians are aware of this threat to patient care, recognizing the balance that exists. Constant contact with suffering patients can overwhelm and sometimes emotionally paralyze a compassionate clinician; emotional burnout can occur. Still, the fact that compassion and emotional involvement are sometimes misplaced and excessive should only serve as a warning, not as grounds for emotional withdrawal. Compassion appropriately motivated and expressing good character has a role alongside reason and impartial judgment.⁴

   Whether a spiritual history would have identified Rose's interpretation of her illness is not known; however, for many clinicians, having this information about a patient might be helpful. Pargament et al2 encourage clinicians to take a spiritual history. Seventy of the 126 medical schools in the United States now have courses that train students to take a spiritual history.⁵ This is especially worthwhile when interacting with patients or families who indicate a religious struggle. Pargament et al² say their findings suggest that patients who indicate a religious struggle at the time of the spiritual history may be at particular high risk for a poor health outcome. Like Rose, referring the patient to clergy to help work through these issues may ultimately improve the therapeutic outcome.

Summary

Compassion in healthcare is imperative, especially when dealing with decision-making of a moral nature. Rules, principles, and obligations are important forces in moral decision-making, although the best interest of the patient is most likely served when this is accomplished within the context of virtue.