Tikkun Magazine, November/December 2006

It's Not Just the Economy, Stupid

Genuine Health-Care Reform

By Daniel P. Sulmasy

Sometimes, when a patient is sick, it is because something is mal-distributed within the body—too much fluid in the abdomen; not enough blood flow to the brain. At other times, the problem is more pervasive, even insidious, affecting all parts of the body—not enough sugar anywhere; a toxic metal accumulating in every cell. Sometimes several types of anomalies occur concomitantly, as in kidney failure, in which fluid builds up in the legs and lungs while the whole body is poisoned in its own waste.

It is now almost a cliché to pronounce the American health care system sick. Everyone has known this for a long time. Yet those who have attempted to "doctor" our healthcare system have failed in each of their successive efforts to effect a cure. Presuming always that the problem is solely one of unequal distribution of health-care resources, the doctors of health-care policy have recommended a wide variety of remedies: national health insurance, managed care, managed competition, health savings accounts, extending the number of individuals covered while rationing services through a massive exercise in public utilitarianism. Each failure has been more spectacular than its predecessor. And the system has continued to sicken.

A treatment usually does not work if the illness has been misdiagnosed. I think this is what has happened in the case of health-care reform. The problem with American health care is not merely one of maldistribution, as ugly and lethal a problem as it poses for our health-care system. American health care is more pervasively sick. And what no one seems capable of acknowledging publicly is that this sickness is spiritual in nature. American medicine has lost its soul. And without a soul, nothing lives.

Patients feel increasingly alienated by a system that treats them as objects—first of science, now of economics. Clinicians too—physicians, nurses, psychologists, physical therapists, and others—are beginning to feel alienated from their work. Looking through a scope at the inside of the human colon ten times a day can become as dehumanizing as working in a poultry processing plant. Katie Couric's colon is not very different from yours and mine.

Spiritual Experience and Illness

Yet illness is always a spiritual event. It grabs a person by the soul as well as by the body. Illness raises spiritual questions for all who are sick—questions of meaning, value, and relationship. Our health-care system has long denied the importance of such questions. And that is precisely why it is so sick.

Those who are ill search for meaning. They want to know why this illness has befallen them. They want to know what this illness portends. They want to know if they have anything for which to hope.

Those who are ill question their own worth. This is especially true in America. If an American cannot work, cannot be the object of someone's sexual desire, and cannot exercise control, there is a resultant crisis in his or her value. Illness precipitates such crises. What is the source of my worth? What about me—suddenly a weak, broken, and dependent human being—gives me dignity?

Those who are broken in body are also mysteriously reminded of what is broken in their relationships. They seek reconciliation. They seek forgiveness. They seek to be united with those they love.

Whether raised in a religious context or not, these questions are all spiritual in nature. Each line of questioning has a transcendent term. In and through the experience of illness, the sick person confronts the question of whether there really is a transcendent source of meaning, value, and relationship. Every drop of blood; every wave of nausea; every creak in the back; every skipped heartbeat portends the dark secret of our mortality. Sickness points to the horizon, thereby raising the question of what lies beyond the horizon. The sick person confronts the infinite. American medicine answers with a CAT scan.

Historical Considerations

The relationship between spirit and health should not come as news. In ancient societies, the practices of medicine and of religion were combined in the practice of Shamanism. Similarly, in very ancient Israel, only the priests could heal, in the name of Rophi Cholim (the "Supreme Healer"). Before the Hellenistic occupation, pious Jews were forbidden to seek out physicians, whose practices were considered to be contaminated with the worship of false gods. With the rise of a secular form of Hippocratic medicine, however, Jewish physicians began to appear on the scene, always with the understanding that it was from Adonai that their power and knowledge were derived, and that it was Adonai who had endowed the world with the healing plants and herbs by which the physician eased pain and cured the sick. A few centuries later, Christianity put a very special spiritual emphasis on healing. Most of Jesus' miracles were works of healing the sick. Visiting the sick has always been a Jewish mitzvah, and Catholics count it as one of the special "corporal works of mercy." The first hospitals in Europe were monasteries, in which monk-herbalists treated the sick who traveled far from home or were too poor to consult a physician.

So what has happened?

Centuries of tension between scientists and religious authorities over the extent to which science can replace religion as the ultimate source of explanation for the universe, and long-standing religious objections to medical advancement intended for the betterment of humankind have gradually eroded the relationship between religion and medicine. In the last few decades, the pace of that erosion has accelerated. Even when I attended medical school in the early 1980s we were at least taught to ask a perfunctory question about the patient's religious preference. Now, even that question has disappeared from standard textbook instruction in taking a medical history. Religion and spirituality have been effectively purged from medicine.

Physicians are not the only ones who have contributed to the current state of affairs. The technological success of medicine in the twentieth century has been alluring. The general population has been enticed into seeking immortality in stem cells rather than in faith. Our vocabulary betrays our truest values. We reserve the terms "wonder" for drugs, "miraculous" for surgical operations, and "sinful" for chocolate cake. A colleague once stated that in the neighborhood in which she grew up, to say that one knew a good man meant that one knew an excellent cardiologist or some other medical specialist to whom to refer a friend.

We have all played a part in the purge.

Unfaithful Medicine and Injustice

In recounting the history of the Jewish people, the scriptures tell us over and over that in times of prosperity, we tend to lose our faith. And our misplaced faith invariably leads to injustice. When we value things more than we value people, we always seek to hoard our supply of those things. In the abundance of our medical success, in the rich harvest of our medical technology, we have built towers in which to store our riches and to keep the poor out. This too has been foretold by the prophets.

The economy of medical technology is a zero-sum game, and here is how it is played: There will only be so many stem cells to go around. For me to get mine means that someone else must go without his—unfortunate, but really not unfair. These are the rules. Someone has to be the first to live to 150 years. The price of progress may just be that others will not even have aspirin. This is how a zero sum game is played.

And so, more than 40 million Americans (not counting the undocumented) go without health insurance while we proudly boast of having the best health-care system in the world. We demand every conceivable gadget in a vain hope to avoid dealing with the transcendent questions sickness places before us. If one of us dies, the rest of us sue. It must have been someone's fault. If she could die, so could I. And that could not possibly be true.

Thus the spiritual sickness that poisons our health-care system and the unjust mal-distribution of access to care are intrinsically linked. It is one affliction. And that may be why those who see the problem with American health care as solely an issue of distributive justice have been doomed to failure in achieving genuine reform.

Is There Another Way?

In the 1950s, in a sppech to the American Medical Association, Abraham Joshua Heschel spoke simply, but with remarkable clarity, to the doctors who were in attendance. He said, "To heal a person, you must first be a person."

Only a person can engage the spiritual questions of meaning, value, and relationship. Only a person can apprehend the transcendent term to which these questions invariably point, especially as they arise in the face of illness. Heschel's insight was that only one who has engaged such questions in light of the work of health care can truly offer to be a healer for a person who has become sick.

Patients today are painfully aware of how depersonalized health care has become. They are increasingly dissatisfied with their care. The better it has become technically, the more it has accomplished, the longer it has helped people to live, the less satisfying the experience has become. Psalm 33 echoes in the heart of every patient: "Despite its power, medicine cannot save."

Medicine today has erected enormous barriers to protect itself against the spiritual reality that its official teaching rejects. Like the builders of the Berlin Wall, medicine has established checkpoints to prevent anyone inside its domain from venturing too close to the spiritual.

When the eyes of both the patient and the practitioner are focused on an image projected on a screen rather than each other, questions of meaning cannot possibly be addressed. Transformed by managed care into a "resource-utilizing unit," it is almost impossible for a patient to sense that he or she is valued as a person. In a seven-minute office visit, establishing a genuine patient-physician relationship becomes a romantic dream. Such medicine crushes the spirit. And patients are beginning to recognize and understand their predicament.

New Trends

In reaction to these developments, there has been a resurgence of interest in spirituality and health care. Bookstores now regularly feature works on spirituality and coping with specific diseases. The self-help literature includes many treatises describing how particular spiritual practices can help to prevent certain illnesses. Some of this can be very banal. But it does represent the inevitability of the transcendent questions that sickness always raises, and the irrepressibility of the human spirit in the face of such questions.

Clinicians, too, are expressing a new interest in spirituality. In the medical journals, much of this has taken the form of empirical research about the physiological effects of spiritual practices and the impact of religious belief and practices on health-care outcomes. Sadly, many of the authors of these studies, while well intended, have been so co-opted by the positivist attitudes of medicine that they fail to see how such studies tend to trivialize the transcendent and in fact border on idolatry. Sometimes spirituality can be very bad for one's health, and one need not go much beyond Jesus of Nazareth, Mahatma Gandhi, or the Rev. Dr. Martin Luther King, Jr. to understand this. What rabbi, pastor, or imam would seek a congregation filled with people who are there for the health benefits?

Yet even more encouraging signs of a movement to rekindle the spirit of medicine are becoming apparent. Most patients simply want medicine to recognize them once again as whole persons and to understand them as beings in relationship to the transcendent. Surveys report that most patients in the United States (with the exact percentages varying with geographic region) want their physicians to address their spiritual needs. In one survey, 48 percent even expressed a desire to have their physicians pray with them. This is not just a phenomenon among Southern Protestants. In one survey, even 45 percent of patients with no religious beliefs thought it appropriate for physicians to inquire about patients' spiritual needs. Needless to say, exceedingly few ever have such an experience in our health care system.

Clinicians, too, are undergoing a spiritual re-awakening. To borrow a phrase from twelve-step spirituality, one might say that physicians, nurses, and other health-care professionals have "hit bottom." Dissatisfaction is rampant. Physicians are retiring early. Fewer students are applying to medical school, and fewer medical students are applying to residencies in primary care—general internal medicine, family medicine, and pediatrics—the specialties that have traditionally offered the best chances for relating to patients as persons. Clinicians are looking at their own professional work for answers to those same spiritual questions about meaning, value, and relationship. Searching for the spirit in a system that denies the spirit, and finding ourselves backed against medicine's Berlin Wall, there is no way out but up, with a desperate cry to God.

Healing American Health Care

Heschel once wrote, "Religion is medicine in the form of a prayer; and medicine is prayer in the form of a deed." If that is true, what would twenty-first century medicine look like if it were considered a prayer?

First, there would be no need to deny the importance of science or to establish an "alternative" form of practice. Adonai still gives us the knowledge and has endowed the earth with the sources of healing. Medicine as a prayer will use science for the good of others, while refusing to be reduced to science. Yet neither is medicine as prayer a form of "complementary" medicine. Too many well-intended individuals are urging us to consider prayer an adjunctive form of medicine; another nostrum in the physician's black bag. Medicine as prayer is not a form of practice that adds a spiritual layer on top of scientific practice. Medicine as prayer proclaims that scientifically-based practice is itself the work of God, using science to glorify the Creator and to serve the needs of the sick.

Second, such a form of practice would demand time. Being present for a person demands time. Time provides a space for meaning. Time allows one to show respect for the value of the patient as a person. Time is required to establish a healing relationship. Medicine as prayer demands the de-industrialization of practice. Seven minutes a visit will not be enough.

Third, medicine as prayer would be attentive. Lexically and temporally prior to petition, prayer is fundamentally an act of listening. Traditionally, the physician who is in charge of a hospitalized patient is called the "attending" physician. Medicine as prayer demands reverent attention to the patient, through whom a clinician can hear the voice of God.

Fourth, medicine as prayer requires the acknowledgement of limits—the limits of the human body and the limits of the medical art. As the Christian theologian Paul Ramsey once put it, "the function of medicine is not to relieve the human condition of the human condition." Genuine prayer always makes us humble, and reminds us, first and foremost, that we are not divine.

Finally, medicine as prayer requires social solidarity. A few years ago, at a meeting convened by the Hastings Center regarding hospice care and justice, I recommended that we establish social solidarity as a principle on which to base an argument for more funding for care at the end of life. A Washington, DC policy maker in attendance, while sympathetic to the cause, remarked, "Oh, no. We can't say that. This is America. 'Solidarity' sounds like 'Socialist.' That will surely kill anything we bring to Congress." Medicine as prayer knows the difference between totalitarian communism and love of neighbor, and opts for the latter. Medicine is prayer in the form of a deed, based on the link between the healer and the healed. That prayer is grounded in the solidarity that begins when the healer recognizes, "This could have been me."

Medicine as prayer participates in the Divine economy, which is not a zero-sum game. God changes all the rules. The infinite generosity of the Almighty has the power to inspire liberality of spirit in the faithful. The loaves can be multiplied. There can be enough for all.

Genuine health care reform is not merely a matter of economic policy. To be more just, medicine must first recover its soul.

Dr. Daniel P. Sulmasy, OFM, M.D., Ph.D., is a Franciscan Friar, internist, and philosopher, teaching and practicing at St. Vincent's Hospital and New York Medical College. His latest book is The Rebirth of the Clinic: An Introduction to Spirituality in Health Care.

 Source Citation

Sulmasy, Daniel P. 2006. It's Not Just the Economy, Stupid: Genuine Health-Care Reform. Tikkun 21(6): 48.