[Dr. Tracy A. Balboni is Associate Professor of Radiation Oncology at Harvard Medical School. Her primary research interests are in palliative care, including the psychosocial aspects of advanced cancer and radiotherapy for palliation. Within the psychosocial aspects of advanced cancer, she has a particular focus on the role of religion and spirituality in the experience of cancer. This includes the impact of religion/spirituality on coping and end-of-life medical care and the impact of spiritual care in the medical setting on patient end-of-life outcomes. She and her husband, Michael J. Balboni, co-wrote Hostility to Hospitality: Spirituality and Professional Socialization within Medicine. She spoke to Charles Camosy.]

Camosy: Can you tell us a bit about the backstory of how this book came to be? It isn’t every day that you hear of two married Christian professors at Harvard Medical School – one an oncologist and the other a theologian – coming together on a project like this.

Balboni: In the early part of our marriage, Michael and I both knew a calling to work together. At the time, I was finishing medical school and heading into radiation oncology residency training, while he was starting a PhD program in practical theology. We scratched our heads a bit wondering how that calling to work together might ever come about. As trainees immersed in our respective fields of scholarship, the chasm only seemed to grow wider and more insurmountable. Yet as I cared for patients day after day, that gaping scholarly chasm, though present, grew steadily more irrelevant.

Caring for patients facing life-threatening illness inherently shines light on spirituality, not only for patients and their families, but also medical caregivers of patients facing suffering. One cannot face serious illness and dying, whether as a patient or one called to care for those suffering, without being confronted with fundamental questions of human identity, purpose, and value. Hence, Michael and I found a way to steer our paths towards one another – focusing on the experiences of patients and caregivers of patients with advanced cancers. We worked together on a mixed qualitative-quantitative study of terminally ill cancer patients and medical caregivers of those patients, inquiring about the role of spirituality and religion in illness and on the perceptions of patient and medical caregivers of spiritual care – the recognition of spirituality as part of care in serious illness and attention to spiritual needs.

The study was eye-opening for both of us as it underscored the simple fact that, in the words of a thought-leader in this field, Dr. Daniel Sulmasy, “illness is a spiritual event.” This study of patients and medical caregivers also raised a conundrum that we recognized should be addressed employing our complementary scholarly perspectives. And that conundrum is as follows: Though serious illness and medical caregiving are spiritual events for patients and for many medical caregivers, medicine largely ignores this aspect of illness and healing. And this disconnection is despite a rich history of interconnection of various major faith traditions and the practice of medicine. And so we endeavored in this book to address the layered issues underlying this puzzle.

One of the things I found most heartbreaking about the results of your research is that so many people desire a spiritual and/or religious component to their medical care, but medical teams generally don’t offer it. Even from hospital chaplains. Can you give us the bottom line about why you think that is the case?

On a practical level, the answer to your question is that most medical clinicians do not receive sufficient training. In the aforementioned study of nurse and physician caregivers of cancer patients, though majorities viewed spiritual care to be an important and appropriate aspect of care, most did not provide it. The most powerful predictor of providing spiritual care to patients was spiritual care training.

Of course, this answer simply begs another question. Why aren’t clinicians trained? Clinicians are increasingly offered courses. For example, Dr. Christina Puchalski of George Washington University has led efforts with the American Association of Medical Colleges to ensure spiritual care competencies are included in medical school curricula. Despite this progress, however, the culture of medicine undermines these efforts. Due to social, technological, and economic forces, the extant ethos of medicine is to neglect and even be hostile to the spiritual dimensions of illness and caregiving.

Just as an example, a chaplain recently told me a story of his interaction with a seriously ill patient who was very closed to discussions of her terminal illness and to any spiritual conversations. The chaplain visited her regularly, and one day there was a breakthrough in their conversation, and she opened up about her fears about her illness and her spiritual questions and struggles. Just then, the medical team abruptly walked into her room and interrupted their conversation, without even acknowledging the interruption. The chaplain politely excused himself, but later returned to the patient who was appalled at how rude the medical team was. What gives a group of well-intentioned clinicians such blindness to even such basic rules of common courtesy? Their actions betray that they are acculturated to view their technical and material goals as having far greater value than all else that can occur in the hospital, including a chaplain’s steady care culminating in a deeply meaningful conversation with a dying patient.

And very often people on the medical team–including the attending physician–are personally religious, right? And yet the secularizing structures you mention keep them from having those beliefs affect the care they give their patients. 

It’s a bit jarring to think that in all likelihood a majority of the clinicians who barged into the room of that patient talking with the chaplain are themselves religious or spiritual individuals. A survey-based study of physicians (Curlin et al. JGIM 2005) demonstrated that 77 percent consider themselves religious or spiritual and 55 percent indicate that their religious beliefs influence their practice of medicine.

These statistics underscore how the forces influencing the culture of medicine have power greater than that of any individual. Most clinicians do not intend for their own spiritual and religious identities – often prime motivators to pursuing the practice of medicine – to become deeply hidden and to only occasionally pepper their clinical practice. But that is the mold that medicine’s culture imprints on clinicians, a mold shaped by social forces such as economics, technology, bureaucracy, death-denial, and a sharp body-spirit dualism.

You are so careful in trying to reach an audience which might be skeptical of your point of view. What are the early returns? Are they taking your research and arguments seriously?

We’ve had terrific engagement both by those that think the ideas ludicrous and by those that agree with many of its premises. For example, there was a dedicated issue in the social sciences journal Society, with both thoughtful and often quite critical engagement. Another dedicated issue is underway in a European journal Spiritual Care. Whether criticisms or praises – that there is engagement with our book’s ideas and juxtaposition of them with those of others means the work is provoking movement and further thought. Certainly, to move the practice of medicine further, such wrestling is needed.

In the final part of your book, you give us reasons for hope in the future development of health care with regard to the subject matter of your book. What are some reasons to be hopeful?

We have reasons to hope. We hope in the fact that fundamentally medicine is a spiritual practice. Human life is more than its mechanical parts, but something of eternal value to be honored and upheld. We are hopeful because an eternal reality greater than ourselves is touched in caring for the sick.

As Jesus declares in Matthew 25:36, “I was naked and you clothed me, I was sick and you looked after me.” These spiritual realities have formed the very foundation of medicine. This spiritual root remains, but it requires nourishment to balance the growing weight of social forces such as economics, technology, and bureaucracy. This brings us to a third hope – that of a revived role for faith communities to call for and nurture the sacred aspects of the practice of medicine.

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