Extracted from: B. Neri, Spirituality in Medicine: A New Dimension in the Light of a Millennial Tradition in The patient as a Person, A.Pingitore, M.Iacono Eds, pp 153-170, Springer Nature, 2023
1. Introduction
Unlike Eastern medical traditions, Western medicine has developed by privileging an analytical method that focuses primarily on the causes of diseases and on the attempt to limit their effects by repairing the damage they cause. This approach has led to significant scientific progress, but has also reduced the importance of the human aspect in the relationship between doctor and patient, neglecting the impact of personal experiences on the course of the disease and the results of treatment.
In reality, since it adopted the scientific method, Medicine has pursued the goal of "getting as close as possible" to the exact sciences, forgetting, at least in part, that the latter deal exclusively with chemical-physical phenomena that can be mathematically modeled. For this reason, it was necessary, first of all, to exclude from the field of analysis the subjective experience, which continues to escape this modeling. According to this vision, any reference to the patient's inner life and to the need to give space to his Spirituality, understood as attention to his inner experience and recognition of his transcendence, has long been excluded from the care relationship between doctor and patient. This circumstance has not helped this relationship, since it is only in the context of subjective experience that physical and mental suffering, as well as the fear of death that accompanies the disease, can be placed, analyzed and addressed.
On the threshold of the third millennium, however, the opportunity to allow the patient to cultivate his Spirituality during his illness journey even within healthcare facilities and to make room for Compassion in the care relationship has emerged ever more clearly: Compassion understood in the sense of bodhicitta, a Sanskrit term that represents the cultivation and development of empathy for the suffering of others.
Compassion thus enters fully into the caring relationship, naturally grafting itself into the broader context of the relationship with suffering: Compassion not as a pitying and somewhat detached attitude towards a less fortunate “other”, but as the result of a deep awareness of the fact that all of us, as sentient beings, are continuously exposed to suffering. Cultivating bodhicitta is a specific spiritual practice to which Buddhism pays much attention, providing specific techniques to develop it. One of these is the so-called “Loving Kindness” meditation [3]. This type of meditation, like others, has also been studied from the point of view of its neural correlates [4]: specific and well-characterized changes have been observed in the EEG trace that have provided a clear example of how a trained mind can modify physiological parameters. A mode of interaction has emerged that goes in the opposite direction to that hypothesized by Neuroscience: no longer the mind/consciousness generated as a necessary product of neuronal correlates, therefore of the brain, but rather the mind/consciousness capable of intervening on such correlates, thus modifying brain activity.
: The crucial moment, however, of the mind/body relationship remains, according to the Buddhist vision, the moment in which this relationship dissolves: the moment of death which is also the moment in which the conditions for the subsequent rebirth are set. The process of dying, the transition state (bardo) and rebirth are described in the Tibetan Book of the Dead (Bardo Todol is the original title in Tibetan, which "... is one of the most impressive works of the culture of all time and collects the teachings on life and death preached by the semi-legendary figure of the great master Padmasambhava" [8]. The maximum point of expression of Compassion towards the dying person is achieved during this crucial phase of the life cycle when the disciples or the people closest to the dying person read in his ear some passages of the Bardo Todol to help him understand the phenomena he is experiencing in the land of passage, when the consciousness withdraws from the now consumed body, thus depriving it of its vital breath and begins its journey that will lead it to the next reincarnation.
2. Spirituality in the institutional context
Spirituality, as defined above [1, 5], mainly concerns the personal sphere and cannot be measured and reported in statistics. Therefore, in almost all research and reviews published in Western medical journals, adherence to a recognized religion and active participation in a community that recognizes itself in that specific religion is used as an observable indicator. It is therefore a concept of Spirituality that is more oriented towards formal adherence to a codified vision, rather than one centered on personal interior experience.
Despite this not insignificant limitation, however, a first step has been taken towards the gradual recognition of the positive role of Spirituality in the course of the disease and in the effectiveness of treatments. An extensive bibliography on this topic can be found, for example, in [10] whose conclusions are reported below [10 references contained therein]:
Overall, the results of the review of the scientific literature on the subject have indicated significant effects of Spirituality on health, a result frequently mentioned in several studies [9, 14, 53]. Numerous studies have indicated that Spirituality had a favorable impact on recovery, improved well-being [2, 29, 11, 12, 13] and lowered depression levels [2, 47]. The positive effects of Spirituality on health are therefore more tangible [16, 17], even if the use of a positive religious compliance strategy does not necessarily reflect a lack of internal Spirituality.
Due to lack of space and in order not to distract the reader's attention from the vast literature available, we refer to the Consensus Report contained in [5]. These are the main conclusions:
a. The patient who enters the health care facilities feels more like a “disease that needs to be cured, than like a person with complex needs, including spiritual ones.” He/she is overwhelmed by the apparatus and its offer of diagnostic tools and pharmacological remedies. He/she is not encouraged to use his/her own internal healing resources. His/her desire for compassionate care to reduce the stress of the disease is unsatisfied.
b. Several healthcare institutions have developed specific guidelines to address this need, shifting the focus of care from just the physical needs of patients to the care of the whole person.
c. It is very important that the patient perceives a compassionate attitude in doctors and nurses. Unfortunately, “Compassion is a spiritual practice, a way of being, a way of serving others and an act of love”. So it is very difficult to introduce this aspect through guidelines and suggestions as it requires an attitude towards Spirituality, the sense of transcendence, meaning and purpose, based on a deep process of inner transformation.
d. In conclusion it is noted that “Health care models around the world must be transformed into systems that honor the dignity of all people (patients, families and health workers); models should be centered on relationships with individuals and communities; Compassion should be the driving outcome for any health system”
Finally, to facilitate the transition to a Medicine that is more attentive to the spiritual needs of the patient, some actions are indicated:
(1) develop proposed standards of care, (2) articulate the characteristics of a compassionate health care system, (3) identify barriers and assess opportunities, (4) develop recommendations and implementation strategies, (5) develop immediate and long-term goals, and (6) create a coalition for change that would issue a call to action that could be used to encourage the development of health care systems that are spiritually and compassionately inclusive.
Compassion is fundamental, but it cannot be imposed with rules and manuals, but must be educated and stimulated both in the individual and in society.
3. The individual context
Some of the problems that have emerged in the integration between Medicine and Spirituality, as highlighted in [5], can be overcome if actions at the institutional level are combined with those at the individual level. The aim is to promote, both in the doctor and in the nursing staff and in the patient, an openness towards Spirituality as described in Section 2 and recognized in [5], with various nuances and emphases. This personal approach does not conflict with the institutional one examined in the first part of this section, but rather strengthens it, making it effectively feasible. It is an education of the mind that aims to reduce the stress related to the disease, developing awareness and maintaining an attitude of detachment and non-attachment towards the perceptions coming from the five senses and those that emerge from the "sixth door" of Buddhist epistemology: the Mind.
The practice of Mindfulness, which has become widespread in the West over the last 30 years, allows us to develop awareness of mental phenomena and their dynamics, although at a much shallower stage than that required to reach the levels of awareness, knowledge and inner calm that are the goal of many mystical-contemplative traditions. It is an effective tool for dealing with the suffering caused by illness, old age and the fear of death. On this basis, Mindfulness Based Stress Reduction (MBSR) protocols [7] have been developed, compatible with active participation in working and social life, with the aim of cultivating awareness of one's mental state and the control of negative emotions. In this context, the intense emotional stress experienced by doctors and nurses in the continuous confrontation with suffering and the sense of impotence in the face of the progressive and unstoppable progression of the disease should not be underestimated.
We leave it to John Kabat-Zinn [6, p.71] to explain how the internal practice of Mindfulness can be used to deal with the suffering of illness.
“Pain is a natural part of the experience of life. Suffering is one of many possible responses to pain… it is not always the pain itself but how we see and respond to it that determines the degree of suffering we will experience. And it is the suffering that we fear most, not the pain… Several classic laboratory experiments with acute pain have shown that tuning into sensations is a more effective way to reduce the level of pain experienced when the pain is severe and prolonged than distracting oneself… the sensory, emotional, and cognitive/conceptual dimensions of the pain experience can be decoupled from each other, meaning they can be held in awareness as independent aspects of the experience. This decoupling phenomenon can give us new degrees of freedom to rest in awareness and hold whatever arises in any or all of these three domains in a completely different way and dramatically reduces the suffering experienced.”
In addition to being helpful to the patient, the practice of mindfulness has been expressed in specific protocols
used to address burnout stress in nursing and medical staff [14], [15], as well as to develop their propensity for Compassion [16-18].
This level of intervention is essential to make the actions identified at an institutional level effective for a complete integration of Spirituality in the path of illness and healing. To this end, it is important to recognize that the concept of Spirituality to which we refer here has an intimate dimension and is independent of adherence to an officially constituted religion, in the sense that it does not exclude it or consider it necessary. For greater clarity, we could define it as secular Spirituality.
4. Conclusions
Negli ultimi 30 anni, anche in ambito medico/scientifico, è cresciuta la consapevolezza dell’importanza di proteggere, durante il percorso terapeutico del paziente, uno spazio intimo in cui egli possa concentrarsi sulla sua vita interiore. Questo spazio dovrebbe essere dedicato all’esplorazione del senso e dello scopo della vita e della morte, mantenendo aperta una finestra verso il trascendente. Abbiamo definito questo atteggiamento con il termine “Spiritualità”, distinguendolo dall’adesione formale a una Religione ufficialmente riconosciuta e codificata. Numerosi studi hanno dimostrato che questa attitudine, che spesso, ma non necessariamente, si esprime attraverso la partecipazione a una comunità religiosa, ha effetti positivi non solo sull’umore del paziente e sulla sua capacità di affrontare la sofferenza legata alla malattia, ma anche sull’andamento e sugli esiti della malattia stessa. È stato anche riconosciuto un valore, altrettanto importante nel percorso di cura, alla necessità di fornire al personale sanitario, medici, infermieri e caregiver, gli strumenti per affrontare lo stress derivante dal continuo confronto con la sofferenza e dal peso delle responsabilità che gravano sulle loro spalle. In questo contesto, è fondamentale che il paziente possa sperimentare, nel rapporto con il medico, un atteggiamento di gentilezza amorevole, intesa come una comprensione profonda della sua sofferenza e delle sue necessità, non solo fisiche. Pertanto, se sul fronte istituzionale è necessaria una presa d’atto di questo stato di cose che darà origine in futuro alla introduzione formale di spazi, competenze e sensibilità nei protocolli e nelle organizzazioni e strutture sanitarie, dall’altra è necessario comprendere che anche l’atteggiamento intimo sia del paziente che del personale sanitario deve aprirsi alla pratica della consapevolezza dalla quale si svilupperà spontaneamente una visione carica di empatia per la sofferenza dell’altro. È fondamentale che il paziente sviluppi un atteggiamento mentale diverso nei confronti della sofferenza e della paura della morte, mentre il personale sanitario deve essere supportato nel ricostruire il legame personale con il paziente, troppo spesso sostituito da un’attenzione esclusiva alla malattia.
