The elderly Hmong woman sat beside her family as the neurologist explained that she would die without the surgery her husband refused to permit.
The doctor said a blood vessel in the nearly unconscious woman's brain had ruptured, filling her skull with blood. In a slow, loud voice he described how the pressure was pushing her brain into the hole at the base of her skull, according to Kathie Culhane-Pera, a St. Paul, Minn., physician who witnessed and took notes on the exchange. The condition, known as a brain stem herniation, would cause a fatal stroke. The only solution was drilling holes in her skull and draining the blood, the neurologist said, his impatience beginning to show.
The family members began debating in their native Southeast Asian language. Her children urged immediate surgery. But in Hmong culture male elders hold authority, and her husband said he would rather let a Hmong priest heal her with chants and prayers.
The real problem, said the husband, was that one of her souls was lost.
"If you take her home, she'll die," the exasperated neurologist shouted. The suffering woman, who requested that her name not be used but who confirmed her experiences through a relative, remained quiet as her husband argued. Then the surgeon, a devout Christian, entered the room. "It is up to this family to connect with its own spiritual needs," he told the group, according to Culhane-Pera. He turned to the father. "If your prayers don't help, I'll be here waiting for you."
Culhane-Pera was certain the woman would die without surgery. In response to the questioning looks, she remained silent. "I felt the decision had to be up to them," she said.
The family left.
Medicine, spirituality and religion have long been intertwined. The Hippocratic oath — a code of ethics that still guides contemporary physicians — originally pledged fidelity to Apollo, the Greek god of medicine. In the Middle Ages, priests in monasteries learned about anatomy and the pharmacology of plants. The first hospitals were attached to churches.
But tensions quickly emerged: Clerics were forbidden to perform surgery in 1215. Soon after, priests were ordered to stop accepting payment for medical services, giving rise to a professional class of doctors.
By the early 1800s, British epidemics pitted government scientists who blamed water sources against priests claiming that disease had celestial origins. The struggle came to a head in 1854, when a cholera outbreak ended after government workers dismantled a well.
Over the ensuing years, medicine increasingly became the province of science in Europe and the United States. But the spiritual origins of healthcare persist: Religiously affiliated hospitals account for 20% of U.S. inpatient care, according to a 2002 study.
As little as 10 years ago, Culhane-Pera's tolerance for spirituality in medical decisions would have been unthinkable for many. Although a 1994 study found that 77% of Americans felt physicians should address patients' spiritual needs, the same study discovered that only 11% of doctors actually participate in such discussions.
But within the last decade attitudes have changed. Today 101 medical schools incorporate patient spirituality in their curricula, up from 17 in 1995. Some hospitals, such as UCLA Medical Center, encourage physicians to include spiritual histories in patients' charts.
However, the medical community remains divided over decisions like those confronted by Culhane-Pera. Some physicians say embracing spirituality has dangerous unintended consequences. Others say doctors should prescribe prayer.
At the core of the debate is a disagreement over physicians' authority and the ethics of endorsing patient beliefs when they conflict with science.
Some, like Dr. Harold Koenig, director of the Center for the Study of Religion/Spirituality and Health at Duke University, applaud Culhane-Pera's choice.
"I recommend that physicians ask every patient if they consider themselves spiritual or religious," said Koenig. "Doctors should encourage prayer and religious participation if that is a source of comfort. Religion has a power to heal, and we have an obligation to value that alongside medicine."
But other scientists, among them Richard Sloan, professor of psychology at Columbia University, say it is dangerous to recommend treatments that push beyond scientific realms.
"If a patient has terrible pain and manages it by watching pornography, rather than prayer, should a doctor tell them to keep it up?" asks Sloan. "It's not a physician's place to make nonmedical recommendations. Spirituality is not guided by science, and doctors must be scientists before all else."
Culhane-Pera said her decision to encourage the Hmong family to make its own choice was influenced by an emphasis on cultural and spiritual sensitivity in her own medical training. Such training is becoming common.
On a sunny afternoon in January, about 30 UCLA medical students crowd into a small hospital conference room to begin their instruction in spiritual healing. The medical school's curriculum is partially funded by a grant from the John Templeton Foundation, established by a religious Wall Street investor "to contribute to the reintegration of faith into modern life." Forty-five U.S. medical schools have received grants of up to $50,000 to bring spiritual awareness into their classrooms.
The students' training begins by detailing what spiritual support should not include.
"We provide spiritual care, not advocacy," Rabbi Micah Hyman begins after introducing himself to two students who will shadow him for the afternoon. Until 40 years ago, hospital chaplains were primarily Protestant, limited to military hospitals and typically present only when patients neared death. Today many medical centers employ chaplains of various faiths who offer assistance to everyone.
"Our role in providing spiritual care is not to diagnose," Hyman tells the students as they prepare to visit a patient dying from AIDS and his mother. "Our role is to listen to what patients tell us they need."
Rabbi Hyman and Victor Sai, a 22-year-old first-year medical student, walk to the AIDS patient's bedside. He is nearly unconscious. As Hyman speaks with the mother, Sai stares at beeping electronic equipment keeping the patient alive. He looks everywhere but at the patient himself, whose swollen hand twitches and whose chapped lips support a respirator hose.
The mother takes her son's hand and looks at Sai. "I don't understand why God lets my son suffer this way," she says, beginning to cry.
The experience leaves Sai uncomfortable, he says afterward.
"I think one or two lectures on spirituality and death would be sufficient," says Sai, who says he doesn't have strong spiritual beliefs. A 1998 study of physicians found that 64% say they believe in God, contrasted with 95% of all Americans. "A lot of us don't believe in spirituality per se; we're more science based. I'm not sure I can relate to a patient's spirituality."
That hesitancy to address patients' nonmedical issues is what teachers hope to correct, says Rev. Sandra Yarlott, director of spiritual care at UCLA.
"Medical students are interested in science, not spirituality," she says. "But doctors need to also provide emotional support." The spiritual component of the lesson is less important than teaching empathy, Yarlott says.
But other advocates of spirituality in medicine argue that physicians should actively engage patients in conversations about spirituality.
"Letting a patient know you respect their beliefs helps them relax," says Koenig. "Just asking can validate a patient's spirituality."
That validation, however, worries some people.
"A doctor is an authority figure, and even his questions carry weight," says Sloan. "What if a patient believes he has a disease because it is a punishment from God? Asking about that belief can validate it for the patient."
Hospital clergy echo concerns that limited training will confer an inappropriate sense of authority.
"The danger is that a physician will overstep because they're not aware of how their own beliefs influence their perceptions," says Yarlott.
That concern is familiar to Culhane-Pera. A few years before seeing the woman with the brain stem herniation, she treated a 20-year-old Hmong man with kidney failure whose father chose spiritual guidance over dialysis. Culhane-Pera ordered the family to cooperate with the hospital, and they agreed to save the young man's life.
In another case, Culhane-Pera withheld her opinion as a Hmong woman's family refused kidney treatment. In spite of the woman's prayers, she died. Culhane-Pera remains uncertain that her different choices reflected the patients' culture: The decisions, she says, are products of her own bias that youth deserves protection. But Hmong tradition dictates that older persons deserve more protection.
In difficult situations like those confronted by Culhane-Pera, the ethical response is referral, says Yarlott: "We encourage physicians to refer spiritual questions and concerns to hospital chaplains the same way they would refer a biopsy to an oncologist."
Practicing physicians say that although it is clear when medical referrals are appropriate, spiritual issues often are ambiguous.
In a recent journal article, Dr. Jerome Groopman of Harvard Medical School described treating an Orthodox Jewish patient who believed her breast cancer was a punishment from God for an adulterous affair. Groopman, drawing on his experience with the Jewish faith, engaged the woman in spiritual discussion but was unable to persuade her to accept chemotherapy.
"I had stepped out of the foundation of fact and knowledge into a quagmire of emotion and imagination," Groopman writes. "I was in over my head." Groopman honored his promise not to discuss the patient's religious beliefs with others. The woman eventually sought treatment, but too late. She died at 34.
The episode, say Groopman and others, illustrates the complication of introducing spirituality into medicine: Unlike observable science, there are few clearly right and wrong answers in spiritual issues. While medicine urges standard diagnosis and treatment, spiritual ministrations are highly subjective.
After the Hmong patient with a brain stem herniation left the hospital, Culhane-Pera went to the woman's home to observe the healing ceremony.
The Hmong spiritual tradition believes in multiple souls, explains Kang Ye Yang, 70, the shaman who performed the woman's ceremony. "Western medicine doesn't believe in spirits," Yang said through a translator. "That is why so many patients die in hospitals. The doctors treat the body, but they have nothing for the spirits."
That night, the shaman began by burning incense and throwing animal horns to communicate with the spirits. The burning herbs' sweet scent filled the room as the family and Culhane-Pera watched the priest balance the incense across a large bowl. He then plunged a knife through the smoldering bundle. The shaman entered a trance, communicating with unseen spirits until he determined that one of the woman's souls had returned to Laos for reincarnation. A long ceremony would bring it back.
The next morning, after the ceremony's completion, the woman was still unconscious. Culhane-Pera was shocked that she had not died. "She is still sick," she told the woman's husband. The family agreed to return to the hospital.
"What we didn't realize is that the family never disagreed with the medical diagnosis," Culhane-Pera said. "But they felt that if she was operated on before her soul was in her body she would not survive."
At the hospital, the surgeon invited the shaman to join him as he reviewed the case and prepared for surgery. The woman was brought into an operating room where the surgeon drilled small holes into her skull. The blood was dark as it drained out. The reduced pressure permitted the brain to re-expand. Within hours, the woman was conscious again and the intense headache and stupor were gone.
"The fact that the surgeon had told the family that he understood the importance of their spiritual beliefs was really influential in encouraging them to come back to the hospital," said Culhane-Pera. "They could have easily decided to stay home. But by respecting their beliefs, we were able to save the woman."