Spiritual Assessment in Three Questions

The following article was was published in PlainViews, the online journal for chaplains, on October 4, 2011. (Vol. 8 No. 17) I was happy for the publication. However, since PlainViews is a subscription journal (only limited articles are available for free), I'm aware that many may not have seen the article. Now that the next edition has been released (10/19/2011 Vol. 8 No. 18), I am now posting the article here.


A further note about PlainViews: while full access requires a subscription, many chaplains find it a worthwhile resource, and well worth the cost. You can find subscription information here. If you'd like to see the kind of articles PlainViews provides, you can find many earlier articles at the PlainViews' Legacy Archive Page. Peruse and see for yourself the quality of the material available.

Any profession must take on the task of setting standards of practice, and chaplaincy has been no exception. Especially important for chaplaincy has been the concept of spiritual assessment or diagnosis. Beginning with Paul Pruyser’s book, The Minister as Diagnostician, those of us in the field have been thinking about, and working to develop, means of assessing the spiritual condition and needs of a patient.

That’s not as simple to do as it is to say. What are the appropriate categories? What sort of language works, and how applicable is it to all patients? Especially difficult in our predominantly theistic and even Judeo-Christian culture (yeah, the institutions may be losing influence, and even coherence, but the vast majority of Americans say in surveys that they believe in God or a Higher Power) is coming up with forms that aren’t Judeo-Christian, or even theistic; because there are more folks around than we used to see for whom those categories don’t work.

I have been working for some time with my own system, and have taught it locally. I would also like to share it with and receive comments from colleagues.

I believe that those aspects of our lives that we might call “spiritual” can be discerned through three questions (with gratitude to Douglas Adams, author of The Hitchhiker’s Guide to the Galaxy series). The first:

“What do I believe about Life, the Universe, and Everything?” Is God, or is God not? Is the universe sensible and aware, or mechanical? Are events random, or somehow organized? Does the arc of the universe bend toward justice, or are we alone in the vast, soul-sucking emptiness of space?

The second question:

“Who am I, in light of what I believe about Life, the Universe, and Everything?” Am I the paragon of creation, or a worm and no man? Am I the result of a million years of random chance, or of God’s creative intervention? Am I alone or in a community? 

The third question:

“How ought I to act, based on who I am, in light of what I believe about Life, the Universe, and Everything?” Am I accountable; and if so, to whom? To God? To my fellow human beings? Only to my own conscience? Do I base my actions on principles, or on my emotions? Am I to do unto others as I would have done to me? Or, am I to do unto others before they do unto me?

As a shorthand, I think of the questions as “Reality, Identity, and Morality.” I think these questions can allow us to appreciate the spiritual circumstances of those we serve, and whether they are properly or maladapted.

Consider, for example, these questions, heard often enough by chaplains: “Why is God doing this to me? What did I do to deserve this?” The questioner believes in God, and believes that God is engaged in creation. Specifically, the questioner believes that God attends to this person, who is individually important enough to God to be under direct judgment. The questioner believes that he or she has some agency, which he or she may have misused, and so is accountable. So, just from these two questions we have some sense of the patient’s Reality, Identity, and Morality.

Alternately, consider this comment: “I’m not really religious. I just try to be a good person.” This suggests that the person believes that creation is orderly and not random, and that the person is a participant with meaningful agency. Indeed, this person believes that behaving properly is sufficient, and that there is no need to participate in a religious community to live in a meaningful way.

These are the categories that help me assess a patient’s spiritual status. With them I am able to develop a plan based on supporting the patient’s self awareness and helping the patient adapt to circumstances so as to live appropriately within the patient’s own beliefs. As the concept of adaptation and function are central to the practices of nursing and other ancillary services, it communicates will with other professions. It is simple to apply, and can be based on the patient’s own comments, without requiring interrogation. Finally, it is respectful of the diversity of our contemporary culture. 

Hearing From Another Chaplain: After the Crash

I've been quiet for a while. I took two and a half weeks of vacation, and between prep time before leaving, and recovery time after returning (a recovery that is still a work in progress!), I haven't had much blog-able in my head, much less time and energy to get it typed and posted.

But I am beginning to catch up, and today took a few minutes to look at some sites I hadn't visited in a while. In the process, I returned to Susan Palwick's blog, Rickety Contrivances of Doing Good. In addition to being an academic and the author of works of science fiction, Susan is an Episcopal lay minister and serves as a volunteer chaplain in her local Emergency Room. (Which is why there's always a link to her blog on my blog.)  That ER is in Reno, Nevada, recently notable for the disaster at the air races. Susan responded to that mass casualty, and posted her reflection on her blog. I would encourage you to go and read it. I know it's been a while now since the event, but her thoughts are absolutely pertinent.

In health care institutions, and especially in hospitals, we drill regularly to prepare for such events. Such a drill is part of what has complicated this first week back. We drill to have our people and our processes prepared; but, blessedly, such events are actually rare. Whenever a colleague has such an experience and shares about it, it's worth our time to read and reflect. So, go over and take a look a what Susan experienced that morning and learned from her experience. It may well be valuable for you, too.

Rationing? What Rationing?

When discussion comes up of government support for universal access to health care, sooner or later an opponent will say, “That will lead to rationing of health care.” Well, there were two stories today on NPR’s “Morning Edition” that clearly demonstrate that rationing is happening right now.

The first story is about drug shortages. Although I’ve written before about “orphan drugs,” drugs that aren’t profitable for pharmaceutical companies because there are too few patients who need them (although they need them critically) to make a profit, these shortages aren’t of those drugs. They’re about labetalol, a well established drug for controlling blood pressure; and the form of calcium that’s used in IV parenteral nutrition; and a well established drug for ovarian cancer. The difficulties have to do with how few manufacturers there are for many of these drugs. But whatever the cause, the result is the same: decisions have to be made about which patients get the drugs and which don’t. In some cases – perhaps in most cases – there may be a substitute to offer. Often, however, the substitute isn’t as effective, or isn’t as cheap; and sometimes there isn’t a substitute to offer. One way or another, decisions are made about rationing care.

The second story is about the a case presented to the Supreme Court of the U.S. today, the first day of the new Court season. The state of California lowered reimbursement to physicians under Medicaid. However, Medicaid is jointly funded by the state and the Federal Government, and the law requires that such changes be approved by the Center for Medcare/Medicaid Services. At first, the changes weren’t even submitted; and when they were, they weren’t approved. They were put in place anyway, and so patients and providers, both hospitals and physicians, filed suit.

Now, the legal issue before the Supreme Court today was whether it was legal for the plaintiffs to sue. However, in the meantime the result is rationed health care. Medicaid doesn’t pay for all the costs of care (that’s not just an occasional problem; it’s part of how the reimbursement is set) so as to encourage providers to control costs. However, like any other good, you can only cut so much before you start doing damage. The patients who don’t get care because doctors can’t afford to provide care (and, yes, in many cases won’t afford – because, remember, the reimbursement doesn’t cover the costs) are the damage. Costs are “controlled,” and care is rationed.

Now, I won’t pretend: I know that care will be rationed, almost whatever program we provide. However, we can make the decisions haphazardly; or we can have the politically difficult conversation to set community standards about how we will ration. Or, I suppose, we could decide health care is a right, and make the political decision to provide it, including determining how to adequately fund it. Nah, that will never happen.

So, yes, I understand that rationing will happen. I just get annoyed when folks want to pretend that it isn’t happening right now.