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Dartmouth Medical School Dartmouth-Hitchcock Medical Center

Point of View

Meaning and medicine

By Elizabeth Tucker Marshall, M.D.

My colleague Elie Saikaly practices oncology with a twist—his father was a minister, and Elie is a devout Christian. When Elie sits with a patient, discussing a diagnosis of cancer and the options for treating it, he is a technician; he reviews scientific data, outcomes analyses, and side effects. This is easy for him. What Elie dreads, he says, is the moment a patient looks at him and asks, "Doctor, what do you think I should do?" At such moments, Elie wishes he had a chaplain sitting next to him. For, he says, this is the existential question. But its answer lies in the patient's own values, beliefs, family, community, culture, and views about living and dying. It is not a question that most physicians are trained to answer.

Construct: Suffering draws people to the deepest questions. What is the meaning of my life? Who is God? Is there life after death? The suffering person becomes a theologian to create a construct for illness. One of the great theological and most human of all questions is this: Why pain? If there is a good God, why must humans suffer?

The Point of View essay provides personal insight or opinion on some issue in medicine or science. Marshall, a 1987 graduate of DMS, is a family physician in Everett, Wash.

As a family physician who majored in religion as an undergraduate and is currently a student in a master's degree program in theology, I am struck by the importance of understanding patients' "personal theology" when I encounter suffering.

Such beliefs extend beyond the realm of Catholicism or Islam or spiritualism to the inner, complex workings of the mind regarding God/Creator/Source of Life. And they underlie people's response to suffering and dying. Do they see illness as a punishment from God, a consequence of sin? Or are pain and adversity an opportunity for spiritual growth? Are sufferers comforted by a loving God? Or do they feel abandoned by God, alone in an uncaring universe?

Aspirations: Since the 1970s, there has been an increasing body of literature on the subject of health and spirituality. We know that people pray—and that the sicker people are, the more they pray and the more of them pray. We also know that people want their physicians to talk about beliefs, aspirations, and hopes, and that in some cases they want their physicians to pray with and for them.

A 2003 study showed that 66% of patients want their physicians to be aware of their spiritual or religious beliefs. And a 1999 study showed that 45%—almost half—of those who deny having religious beliefs think physicians should ask about them anyway. Although religious polarization seems to dominate today's headlines (the threatened Quran burning in Florida being but one example), a recent Pew Trust study revealed that 70% of Americans believe that many religions lead to life after death; only 24% say theirs is "the only way." So spiritual differences of opinion between physician and patient are not critical to whether the topic is discussed, as long as it is done with respect rather than with intent to proselytize.

My friend Mary Eichinger has two teenage sons. The older one was waiting to hear from colleges when Mary's husband, Joe, was diagnosed with pancreatic cancer. Three months later, Joe died. Mary and I talked about the interactions she and Joe had had with the medical profession during this time. Joe had a poor prognosis from the start. Doctors offered him chemotherapy and he took it, hoping for six to eight months—which statistically would have been a miracle. No physician would answer Mary when she asked "Is this it?" or "How long?" So she felt guilty asking Joe about their sons' college funding and other such concerns. She felt that to do so would imply to Joe that he was dying.

A 2003 study showed that 66% of patients want their physicians to be aware of their spiritual or religious beliefs.

Mary and I discussed how things might have gone had Joe's doctor taken a slightly different approach. In addition to offering every treatment available in the hope of extending Joe's life as much as possible, could the doctor, at the same time, have conversed with Joe about his life, his feelings about the diagnosis, his faith, and getting his affairs in order? What if the physician had said, "You have an opportunity here, Joe, because you have some time. We don't know how much—maybe weeks, maybe months. I want to make sure you take advantage of this opportunity with your loved ones. What is important to you now, and how can I help you carry out your wishes?"

Bridge: Physicians help their patients bridge the gap between suffering and vitality. Yet no physician can eliminate suffering or conquer death. The question is not "Will there be suffering?" but "When and how?" The question is not "Will I die?" but "When and how?" Death is inevitable, suffering is inevitable. Buddhists know this well, and it forms a foundation for their religious practices.

It thus behooves providers of "health" care to first ask themselves these questions: Is there a God, and if so why is there suffering? What is my relationship to my patients' pain? Can I approach suffering with acceptance of its place in the human condition? Can I allow patients the dignity of acknowledging their spirituality in the setting of discussions about medical decision-making?

Physicians' greatest goal must not be to "fix" illness, but to foster an environment in which even that which cannot be fixed can be tended and can lead to conversation about existential questions. The physician's role is to offer that which is, ultimately, larger than technology or science: meaning, independent of outcome. For, as Viktor Frankl wrote, "not only creativeness and enjoyment are meaningful. If there is a meaning in life at all, then there must be a meaning in suffering. Suffering is an ineradicable part of life, even as fate and death. Without suffering and death human life cannot be complete."


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