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.

Yes, Virginia, There Are Evangelical Episcopalians

Among the many places where I'm connected is LinkedIn. If you're not familiar with it, it's much like Facebook, but with an entirely professional focus.  Like other social networking sites, there are topical groups, including one for folks interested in the Episcopal Church. This week one member posted this question: "Are there any fellow evangelical Episcopalians out there?" This was my answer.

I think there are evangelical Episcopalians - by which I mean folks who experience Scripture as central to their faith, and who experience joy in living before Christ and sharing that with others, both within and without the congregation. Few of them are thorough-going Biblical literalists; but most believe the Gospels faithfully relate the experiences of the Evangelists with Christ, and that at least most of the events described, including the miraculous events, are historical.

By and large, they are not tied to a particular style of worship, although they enjoy some "praise" music. As the Prayer Book since 1979 has emphasized the Eucharist as normative Sunday worship, they have the Eucharist on Sundays, and not Morning Prayer. At the same time, most don't attend congregations where the liturgy is chanted most Sundays, or where incense is used, unless for Easter or certain special occasions.

Some of them are uncomfortable about decisions that the General Convention has made. However, they feel established in and supported in their individual congregations, and pastorally supported by clergy even when they disagree with them; and so they continue in the Episcopal Church. They see things changing around them, and regret some of the changes; but they have enough hope in Christ that they don't feel they have to fight things they can't control.

I spend half of my Sundays supplying in one church or another in two adjacent dioceses, and I meet these folks all the time. I'm happy they're with me in worship. 

 I know that the word "evangelical" when applied to an Episcopalian or other Anglican has meant something a little different: a literal use of more of Scripture, especially on social issues; a more exclusivist understanding of salvation; and, unfortunately, anti-Episcopal Church sentiments at home, and that plus anti-American culture sentiments abroad. However, I will stand by this as more accurate to the evangelical Christian tradition as folks live it out in the Episcopal Church; and I'm happy to have them with me in worship, and in my diocese, and in the Episcopal Church.

Remembering the Martyrs of Memphis

Many of my readers will be aware that the Episcopal Church remembers on certain days persons who have been especially noteworthy as models of the faith. Today is the day of Constance and her Companions, the Martyrs of Memphis. It is a day I make note of each year because the Martyrs of Memphis demonstrated their faith, and most of them died, providing health care.

Memphis, Tennessee, was wracked by yellow fever epidemics three times in ten years. The third epidemic occurred in August of 1878. 30,000 citizens – those who had somewhere else to go – fled the city. 20,000 had nowhere to go, and were forced to face the plague. Deaths averaged 200 per day, and before it was over more than 5,000 had died. The city was so depopulated that it lost its charter, and was not reorganized for fourteen years.

There were those who stayed by choice to care for the sick. The Episcopal Church remembers specifically six Episcopal nuns; four Episcopal priests, two of whom were physicians; a third physician; matrons at an Episcopal School for girls; and volunteer nurses and clergy from as far away as New York. However, we also remember that there were laypersons from many of the faith communities in Memphis who stayed: Roman Catholic, Baptist, Methodist, Presbyterian, Jewish, and other clergy and lay workers. They stayed to serve the sick, and died for their compassion. In Memphis today this is an ecumenical remembrance, when all faith communities commemorate one another’s honored dead as they remember their own.

In the last decade we’ve seen so much to make the commemoration of the Constance and her Companions more apt and poignant. We have seen cities wracked with expressions of human evil. We have seen images of another city, a sister city on the same river, emptied of people and filled with sickness and death. We have seen the entire region leveled by storm after storm, storms that continued to rage long after the wind and water appeared to have subsided. This year alone we have seen disaster after disaster, from the devastating tornadoes in the Central Plains; to more flooding in the Missouri and Mississippi Valleys; to the floods in the Northeast and Midatlantic states from hurricane and tropical storm. And we see colleagues providing care, often at great personal risk, to rescue those who can be saved from disease and dehydration, and from the inertia of isolation and shock. We support them in spirit, with our resources, and for many of us, with our prayers.

The Martyrs of Memphis are a part of the heritage at my hospital and health system. While we are not all Christian, much less Episcopalian, we are all in the tradition of health care. Watching the consequences of these events, we know that risks to the health of our communities are risks to us. We continue to serve, knowing of costs we hope we will never have to face. We serve those who come to us, knowing we are not immune ourselves. There is real courage and commitment in our service, and it is the same commitment shown by the Martyrs of Memphis of all faith backgrounds and of none.

As an Episcopal Chaplain, I consider each of my colleagues in health care to be holy and all of their works to be sacred. The compassion and commitment each of them shows reflects, I believe, the compassion of God. Today, as I honor the Martyrs of Memphis, I honor and pray for them; for each of them witnesses to individual faith at personal risk and cost, and reflects the presence of care here at in my hospital and health system, and in the whole of God’s creation.