Spirituality of palliative care

Dr. Anand Amaladass S.J.

The concern for the spiritual accompaniment of the dying persons and their families looms large these days in the Western academic world. Who is responsible for the palliative care? Many think that the pastoral care is the duty of the clerics. The doctors and social workers, on the other hand, argue that they are better suited to this job.

But when we ask ourselves, our friends, and co-workers, whose responsibility it is to find meaning in my loses, crisis in my family or work place, to find God in whatever form, to understand my disappointments and limitations, the majority would say that it is my responsibility. In other words, it is my responsibility to find meaning in daily activities and to face painful eventualities in life. But the spiritual care is not the duty of the auto-mechanic, my friends or the employer. They can be of some help — intended or unintended. But the first step I must take myself.

Today the central concern is health care in general and palliative care in particular. In this connection spiritual care becomes part of it, as something that we do for others. We are responsible for this. How does this awareness come about? Spiritual care is often described as a consequence of psychological assessment and intervention. It consists of verbal act, perhaps an exercise in self-communication or a piece of advice. Others emphasize the ability to listen.

Listening, talking, advising and community thinking with professionals have a place in this process. This is especially important in dealing with people with life-threatening sickness. Spiritual needs possess a great community based components, which the friends and relatives must perceive as their responsibility.

Equating Spirituality with finding meaning in life as important categories for the existential wellbeing is linked with the psychologizing of spirituality or religiosity. It is not merely medicine and personal care, but also psychology raises the question of health-related quality of life. Spiritual care serves not merely as label or etiquette for the traditional Christian pastoral care, but also for the psycho-social accompaniment.

Spiritual care is first all self-care.

It is primarily the responsibility of the patient or dying person to discern what is really important for him/her, what gives a final meaning to his own life and death, what holds him and carries him further in the midst of his experience of fear and loneliness, what lets him hope when faced with doubt and uncertainty. In that sense spirituality is self-care and then care for one another. (Kellehear 2002).

On the other hand, there is also the danger of paternalistic perception of the patients through therapeutic activities. Spiritual needs and desires of the patients are not to be disregarded. The silent adjustment between autonomy and ‘weak paternalism’ is part of clinical daily routine. In that sense the spiritual care remains the task of the clinics. (Eckhardt Frick, 2009)

Dignity arises in relationship.

Dignity is a central concept in the modern discussion about sickness and dying. Not only the fear of death, but above all the fear of “undignified” death forces people increasingly to various forms death, specially suicide. Now what sort of dignity is at stake here and what does it depend on and what has that to do with spirituality?

Narrow understanding of dignity.

What is prevalent today is the notion of human dignity coming from the western philosophical tradition. Worth or honour is first of all differentiated a person (dignity especially a special status, carrier of some worth), later as a sign of human being in contrast to the animals. The worth or dignity- the principal equality of human beings goes back to the stoic philosophy. The German word Würde (dignity) is etymologically connected with Wert (value). The discussion after Emmanuel Kant emphasizes that it is the inner worth, value, which is inborn, incommunicable, unmistakable, non-derivable. It is about the rational, individualistic, anthropocentric aspects. The characteristic of Enlightenment is the emphasis of autonomy, freedom of will, self-responsibility.

Dignity needs the Other (who stands face to face)

In the great religious traditions dignity is associated with abilities of human beings. If the dignity is a certain quality like reason, and intellectual knowledge, then it is limited to human beings and not all living beings. Then it is again limited to men and not to women. Again it is only to the elite and educated ones and not to the rest of the masses.

Dignity (Worth) is in the first place a relational concept and grows out of a relation between God and human beings or out of the fundamental cosmic connectedness. The human being can be related to a personally believed Divinity — man as the image of God, God’s representative, partner of the Godhead. On the other hand, the connection of all living beings builds the basis of a unity mystic, who expresses in words through a religious transmission — always it has to do with it in order to overcome the bondage with the ego. Human being recognizes himself in all other living beings. Thus dignity arises from the identification with others.

Dignity cannot be lost or taken away.

Dignity which results from a relation to a transcendent reality or from a cosmic connectedness, cannot be lost, even if some human characteristics or abilities like understanding or memory power go astray. One who loses a chance or opportunity to show his worth can experience his worth, as he is honored by others.

Worth is not connected with autonomy, but in relationship, in greater connection and inter-independence. In the religious traditions human being is not looked at as isolated individual and the life is not oriented to a self goal, but integrated with a greater whole and oriented to a transcendent goal. In modern times the perspective is strongly oriented to the survivors of the dead. The most known cultures and religious traditions have a rich heritage of the care of the dead, which corresponds to the dignity of the dead. So the dignity of the dead remains also as part of the living community solidarity.

What is then spirituality?

Spirituality is first of all an essential part of the organized religious traditions. In the Christian influenced European Middle Age spiritual things were seen in contrast to worldly, material and bodily things and often related to the monasteries. It is also the core element of every religious tradition in the world –Jewish, Buddhist, Islamic, Hindu etc.

Today spirituality is differentiated from religion. Religion in Europe is often equated with the Christian churches. And since Churches are connected with institutions, dogmas, hierarchy — and also violence and misuse — spirituality is seen by many in Europe in contrast to religion. So modern spirituality and traditional religiosity stand distanced from one another. Modern spirituality represents a type of religiosity, which is anti-institutional, anti-dogmatic, experience-oriented, pluralistic, subjective and partly, but not necessarily, private.

Is there a non-religious Spirituality?

Many sociologists of religion hold the view that contemporary religiosity tends towards broadening in principle the space of religions. It is a dimension that transcends the empirical day-to-day reality. Religious equivalents are discovered in the entire areas of life: wellness, medicine, sport, economy, media, pop-music, etc. are religiously charged. The masses are excited by “God-Football” or the caution board at the end of the street warns the bike riders — “to give a chance to your guardian angel.” Spirituality has become obviously an alternative to religion. Here religion is reduced to an organized religious tradition, namely, the institutional form of great Christian churches.

Pastoral care in hospitals

Spiritual care can be formulated in the following theses: 1. Spiritual care is not a job; 2. Spiritual care is an attitude; 3. Spiritual care arises against the background of a technically modernized, impersonal and achievement-oriented world; 4. Spiritual care considers all people; 5. Spiritual care means “an respectful attitude to people in need”; 6. Spirituality communicates respect, understanding, love. (van der Geest, 1981) Today spirituality is integrated with the training of the medical students, since spiritual care is a team-work.

Facing the dying people with concern

From the beginning of history the experience of death has confronted human beings and forced them to reflect. It is the religious-spiritual dimension, which registers itself from such questions about life, which cannot be developed and practiced without the intensive look at dying and death. All attempts of people to give shape to death, to make the angel of death a companion or to make music and dance — give the insight that death is not some esoteric theme of our life. To accept death and to integrate it with one’s own self-interpretation makes self-development and spiritual growth possible, but also to live together more consciously and humanely with essential relationships and decisive love. So it is not surprising that in the context of discussion on death, the modern society is busy with palliative care and hospice works, drawing attention to the death as existential key to our life.

Modern medicine has not succeeded (and will never succeed) to gain victory over death. The struggle against death has assumed many destructive forms like closing the eyes and hearts out of therapeutics. Only when the medicine in its entirety takes over the relation to death in self-understanding and interprets it, it will gain a new warm friendly relationship to the dying in sickness and to death. Spiritual care is primarily a task to the respective person; with the background of experience, in the concern for the other — is the basis for the contemporary spirituality.

Hospice movement: Christian motivated hospitality.

Inspired by the Christian attitude of “love of one’s neighbor”, respect and empathy, many pioneers in Germany coming from Christian community traditions — members of religious orders, pastors, founded the “hospice honorary post” in the sense of Christian diakonia and Caritas. The British medical doctor and social worker, Cicely Saunders is credited for the opening of the “St. Christopher Hospice” 1967 in London. There hospice and palliative care are used as synonyms. The concept of hospice continues the idea of European oriental hospitality. Human life understood as pilgrim on earth is referred to hospitality in order to find the way and the goal. Hospice offers an unintentional hospitality, unconditional interest in others. This hospice is first of all not a building, but an attitude of persons, a culture in the organization of society.

In Germany the discussion can be understood as an introduction of hospice as places of dying with human dignity against the background of diagnostic experience of “undignified dying in hospital and also in nursing homes.” In 1970s of the 20th century there took place broader social debates. At that time the scandalous death in the shunting yards and glazed bathrooms was the actuality. The loneliness of such death appears inhuman. So the critics proposed a dignified dying, accompanied, in a self-chosen place.

Spirituality of open doors.

“If we believe in God, can we not accept that all religions of speak of Him?” This claim to “open to all” leads to specific praxis of “spirituality” — rituals, use of symbols and also the way of speaking — freeing from specific symbols of “faith traditions.” The strict confession related symbols are to be relativized. Instead natural symbols like light and darkness are to be introduced. Various rituals are possible. Finally, it is the cliental that is characterized by a pluralistic world-view. Individuality is the highest command. Individual and inter-confessional forms characterize the culture of hospice, which is respectful attentiveness.

Hospice attitudes

The term “palliative” comes from the Latin pallium (mantel), in the sense of ‘pastoral support.’ Etymologically this Latin word refers to “pel” meaning “animal skin”, referring to the sheath of swords in war times, therefore ‘protection’. This double aspect of palliative makes possible to take an active role in looking at the affected person and underlines the radical orientation of the person concerned. It is about the proper balance of “too much and too little”, a balance between “prolonging and shortening” the dying span, as WHO in its definition aesthetically formulated it.

Inspired by the dignity of life and dying.

Dying is not a sickness, but a normal part of human life. Dying is not to be pathologically presented. Dying is not a diagnosis, which makes then therapeutics necessary. Dying belongs to life, a simple leap with consequences. So some hospices speak of “guests” and not as “patients.” This perspective of normality lets the dying one appear as the task of humans and social solidarity, as a question of attitude and perception. It makes the hospitality a “promise”- that means the hospice idea is not derived from the social solidarity, but a genuine and indispensable principle of the knowledge of human quality of a society. (Graf/Höfer, 2006)

Inspired by the individuality of life and dying.

People do not live according to a scheme and do not die according to a planned scheme. Every attempt to propose a plan of a linear process of quality development breaks down at the individual claim of life, at the personal and biographical conditions and other expectations of the affected persons.

Here the human life is at the center. The hospice movement takes seriously the affected persons. The spirituality of hospice movement grows out of self-experience, at the borderline, of dying and death. (For more detailed discussion Cf. Birgit Heller and Andreas Heller, Spirituality and Spiritual Care. Huber, 201