Homework for Catherine Owens

O R I G I N A L A R T I C L E

Religion, Spirituality and Health Care: Confusions, Tensions, Opportunities

Stephen Pattison

Published online: 9 April 2013 ! Springer Science+Business Media New York 2013

Abstract This paper raises some issues about understanding religion, religions and spirituality in health care to enable a more critical mutual engagement and dialogue to take place between health care institutions and religious communities and believers. Understanding religions and religious people is a complex, interesting matter. Taking into account the whole reality of religion and spirituality is not just about meeting specific needs, nor of trying to ensure that religious people abandon their distinctive beliefs and insights when they engage with health care institutions and policies. Members of religious groups and communities form an integral part of the structure and fabric of health care delivery, whether as users or in delivery capacities. Religion is both facilitator and resistor, friend and critic, for health care institutions, providers and workers.

Keywords Religion ! Spirituality ! Health care ! Ideology ! Dialogue ! Healing

Introduction

Those who inhabit and embrace the categories, religion and spirituality on the one hand, and health care on the other, often fail to understand both the richness and the confusing complexity of the other. Even health care workers with personal religious affiliations may fail to comprehend the complexities and ambivalences of religion— they know the bit of their own religion that is relevant to them—while ‘non- religious’ managers and clinicians may only have the most rudimentary under- standing of what faith, religion and spirituality are or might be. By the same token, those members of religious communities who have little to do with bio-medically

S. Pattison (&) Department of Theology and Religion, University of Birmingham, ERI Building, Edgbaston, Birmingham B15 2TT, UK e-mail: [email protected]; [email protected]

123

Health Care Anal (2013) 21:193–207 DOI 10.1007/s10728-013-0245-4

oriented health care may have a very limited understanding of its rationale, beliefs and practices. It could be said that while many health care organisations and professionals are illiterate about religion, many religious communities and individuals are equally ignorant about organised bio-medical health care.

Such mutual lack of knowledge and understanding obstructs thinking about concrete accommodations and collaborations between religious individuals and communities and organisations and professionals delivering health care. The beginning of more fruitful understandings and activities must thus lie in greater mutual understanding.

While absolute fairness might demand that half this article be spent addressing each group, I propose mainly to try to expound relevant aspects of religion and spirituality for health care professionals and policy makers, critically evaluating its potential for both collaboration and resistance. The latter is important; religious communities are seldom devoted solely or mainly to enhancing the kind of bio- medically mediated physical wellbeing that is the primary aim of health care of the kind mostly provided in, for example, the British National Health Service (NHS). For many committed religious believers/adherents of faith communities, religion transcends, and is more important than, health care. Health and health care are therefore subordinate to a larger vision and quest for life and, for many, a relationship with the transcendent, that goes beyond social and biological life itself.

Let me start, however, by outlining a few prima facie attitudes to religion and spirituality in contemporary health services. A number of common ‘ideal type’ attitudes can be found amongst health care providers, individually and collectively:

• I (we) don’t understand/need religion/spirituality but I appreciate that other people have a right to their beliefs and practices so long as that does not damage themselves or others and they keep it personal or private.

• I (we) don’t understand/need religion and I think it is generally harmful to people and communities—I will tolerate beliefs and practices because the rules about diversity and equality say I must. If it were up to me, I would keep it out of health care—it’s a personal and private matter.

• I (we) don’t understand/need religion, but I believe that religion and spirituality are a very important part of many people’s lives, whether or not they are to me. On the whole, religion helps its adherents with meanings and relationships so I am in favour of its being an integral part of health care.

• I am a religious adherent and my faith is of enormous importance to me, part of my motivation for going to work. However, I think it is a personal, private matter; I don’t think it should be talked about or mentioned at work because that is not appropriate in a secular space and might be oppressive to some people.

• I am a religious adherent and my faith is of enormous importance to me, the most real thing in my life that determines everything I do. I think everyone should be exposed to religious belief and practice in health care so they can find fullness of life and community. I try to use religious ideas and methods with people whenever I can, but I am afraid if I do so too overtly, I will lose my job because health care is secularised in the UK.

194 Health Care Anal (2013) 21:193–207

123

Of course, these are all partial caricatures of positions that probably no individual holds in reality. However, they bring out some of the starting positions that this paper seeks, somewhat obliquely, to question from the perspective of understanding the nature of religion and spirituality in the UK better.

I will proceed, first, by considering definitions and understandings of words like faith, religion and spirituality. Then I will go on to consider some of the perhaps unhelpful ignorances and assumptions that those outwith faith communities might make about those communities in relation to health care.

Understanding Basic Concepts

The 1991 NHS Patient’s Charter enunciated that people had the right to have their religious and spiritual needs met within the health care system [7]. Health care had always been pervaded with religious ideas and motivations; institutions like hospitals were the product of Christian motives, ideas and practices (senior nurses were called ‘sister’ after their monastic forebears) and they had universal formal religious provision in the form of chaplains from 1948 [13, 24, 29, 36, 40]. However, up till this point, no right to having one’s needs met had been expressed so explicitly. Unfortunately, the Charter did not explain what ‘religion’, ‘spiritu- ality’ or the needs associated with those categories were, nor suggest how they might be met. Subsequently, particularly in chaplaincy and research associated with it, an industry has sprung up to try to explain, contest, and expound on the meanings and practical implications of these words [4, 5, 9, 19, 22, 33, 37]. It is in the context of this kind of contested meaning that it then becomes important to consider what some of the basic concepts used in relation to religion and its cognates are.

Perhaps a good place to start here is by pointing up the distinction between faith and religion. Just as diners tend to talk of eating meals rather than ingesting nutrition, people with strong religious affiliations tend to prefer to talk about having a faith and belonging to a faith community rather than having a religion. This tendency is particularly present amongst committed Christians who may be seeking to make the point that theirs is an active quest not just a passive affiliation, as it might seem to be when one is asked for one’s religion on an official census form. And it should not be thought that faith just means cognitive belief. The Abrahamic, scripturally-based religions (Judaism, Islam and Christianity) do tend to emphasise the importance of believing or agreeing to words and formulations. But they, along with members of other groups, would generally agree that having faith is a matter of actively trusting in a living God and living one’s whole life, body and soul, in the light of that trusting relationship, not just being able to recite a creed or a declaration of faith. So-called ‘believers’ would probably prefer to see themselves as disciples, committed to far more individually and communally than assenting to the right words. Orthopraxis (doing the right thing) is thus just as important as orthodoxy (believing the correct thing).

Immediately we have come up against two of the most important issues facing those who would understand the various words used around religious belief and practice. First, the actual meanings and extent of words are under-specified. When,

Health Care Anal (2013) 21:193–207 195

123

for example, do I cease to be a ‘faithful’ person or a ‘believer’? When I stop thinking that God exists? Or when, even if I continue to believe that God exists cognitively, I stop going to worship or stop behaving as if God’s will should be enacted in my life? In this context it should be recognised that religious adherence and affiliation is a ‘thick’ multi-facetted attachment that involves bodies and bodily habits and practices as well as beliefs [11, 20]. Embodied habits of heart and mind, passively maintained, may far outlast and extend beyond active cognitive commitments for those associated with religious communities. The faithful are bound up in embodied webs not only of beliefs, words and meanings but also of relationships between human and non-human entities and objects, visible and invisible, alive and dead, earthly and heavenly [11, p. 5, 27]. Only some of these significant relationships are conscious and articulate; many are tacit and latent.

This implicitly raises, secondly, the issue of the nature of religious believing and belonging [6]. To put this strongly, how marginal do you have to be to a community of faith and practice to be regarded as a member of it? Many religions have a small minority core of very observant and attendant members, with a larger periphery of occasional attenders, then an even larger periphery of people who have something to do with the religion through ethnic, cultural or family ties, or by virtue of past engagement [34]. Thus there are ex-Catholics who would still identify themselves thus, and ethnic or secular Jews who would not necessarily want to engage with formal practices, but might still find some of their habits and attitudes shaped by or even in opposition to a past sense of religious belonging [16].

This is an important issue here because sometimes people who have been on the margins of religion re-discover or discover faith for the first time on occasions of stress and alienation, e.g., when they are diagnosed as ill or put into prison [12, 37]. Furthermore, marginal members of religions communities may have a limited grasp of their faith, its teachings and practices, and may then be inclined to adhere more fiercely to what they think they do know about its observance in such situations than those who have a greater immersion and more mature engagement. They may therefore be more insistent on access to and respect for external signs and rites than those who are more knowledgeable and experienced in matters of religion. Sometimes, those with this kind of peripheral, poorly-informed engagement with faith are characterised, rather pejoratively as having a kind of ‘implicit’ or ‘folk religion’ which is intellectually unsophisticated and hedged round with participation in a small number of practices deemed to be essential, e.g., baptism of babies, weddings and funerals in church [2]. The question then arises for health care providers, whose religious and spiritual needs should be met and at what level?

Secondly, and more significantly, there may be a gap between how ‘insiders’ of religious groups understand and define themselves and how ‘outsiders’ do so. This is a major feature of the difference between theological and religious studies approaches to their subject matter in the academy [10, 20]. The former tend to value the insider perspective and take it to be prima facie valid and true. The latter might try to look at religious practices more objectively, perhaps reducing them to more sociological or anthropological categories alongside other social movements.

These points are important, because one suspects that when concepts like ‘religious need’ are used publicly, they presuppose that there is some kind of

196 Health Care Anal (2013) 21:193–207

123

objective, unified approach to understanding religion. There are indeed approaches that purport to be objective, perhaps focussing on religious institutions or behaviours, but these may not actually take seriously the pluralism and intensity of insider experience of faith [20]. If I identify myself as faithful not religious, then attempts to meet some kind of externally defined set of religious ‘needs’ may be just as irrelevant to a very committed religious adherent as they are to an agnostic or an atheist.

This brings us to the next set of relevant definitional issues which concern understandings of ‘religion’ and ‘spirituality’. The definitional murk thickens.

The Meanings of ‘Religion’

Religion is a notoriously difficult concept to define satisfactorily [8, 14, 15, 20, 21, 23]. While the communities, habits, practices and ideas that the concept is taken to denote these days may have been around for millennia in some cases, religion as an overall descriptor is really a product of the nineteenth-century Western academy [8, 14, 20]. In the nineteenth century, academics basically compared social beliefs and practices with Western Protestant Christianity, and then decided which of these phenomena could then be described, like Christianity, as religions. Thus scriptur- ally-based groups with an articulated emphasis on thought and ethics tended to be regarded as ‘higher’ religions (e.g., Buddhism, Hinduism) while those who emphasised ritual and practice without much attempt at recorded articulation or formally codified and elaborated moral teaching (e.g., African traditional religions, animists, shamanists) were regarded as ‘lower’ religions, or perhaps as even as ‘superstitions’, collections of non-monotheistic and essentially meaningless prac- tices [8, 20].

In the nineteenth and twentieth centuries, the attempt to arrive at a single, all- inclusive understanding of what counts as ‘religion’ had limited success. Hick argues that it is possible to see family resemblances between all the main religions (he probably means ‘higher’ religions, so is not trying to account for Wiccans or Jedi Knights), but even there, there can be differences which strain even the idea of family resemblance [15]. Buddhism, for example, is not theistic, Hinduism is polytheistic and mediated through images, Judaism and Islam are monotheistic and theoretically will have nothing to do with images, and Christianity is by turns iconophilic and iconoclastic [17]. And this does nothing to account for phenomena that seem to have some of the meanings and functions of established religions like sport, art, and consumerism.

Amidst this confusion, some theorists take a reductionist, functional approach to defining religions [23]. They argue that beliefs are less important than functions so that a certain common set of social functions, e.g., providing a common ideology, providing meaning, belonging and purpose in life are what characterise religions. Such broad understandings tend to make religion so broad and inclusive as to be meaningless. Thus, insofar as football allows people to have a sense of meaning, belonging, hope and purpose in life, it might be characterised as a religion. Functionalist understandings tend to bracket out or to marginalise some of what many believers would hold to be the main essence and importance of religion,

Health Care Anal (2013) 21:193–207 197

123

namely its claim to engender and enhance relations with the transcendent, taken to be ultimately real and significant, what monotheists call God [15].

Functionalist analysts of religion tend to adopt a reductionist, suspicious attitude to religions, regarding them as humanly created instruments of, and surrogates for, some human need or purpose like social cohesion. Thus Freud saw religion as a necessary illusion, while Marx, following Kingsley, saw it as an opiate for the unhappy masses. More recently, and no less reductively, sociologist Emil Durkheim characterised religion as a mechanism for binding individuals and societies together, a kind of social cement. Often, when people are criticising religion, it is precisely such a reductionist, religion is ‘nothing but’ (…an illusion, a comfort, social cement) view of religion that they have in mind. Religion is thus de-throned and disenchanted beneath the steely gaze of the analytic heirs of the Enlightenment for whom God is at most a hypothesis, and the pursuit of the ‘transcendent’ a life choice based on delusion and wishful thinking [38].

This position of suspicion of religion and what it believes about itself on its own terms is very empowering to those who wish to assay the beneficial and malevolent effects of religion. It allows them to treat religion similarly to other human and social phenomena like education or the economy. Implicitly, it informs some of the thinking about the place of religion in secular social policy and health care. If religion is good for people and communities by, for example, enhancing health, then it can be used to deliver social benefits. It not, then, like any other social practice, it must be altered till it does produce those benefits. So if religionists distrust the use of allopathic medicines dispensed by a NHS professional in favour of amulets or prayer from a religious source, then they need to be re-educated to see that this is misguided and to accept medical advice.

Standing more or less diametrically opposite to the functionalist view of religion stands the substantive or essentialist position [23]. This broadly maintains that religions should be understood on their own terms and not be reduced to their social functions. Thus if religions say that they believe in and worship a transcendent God, this should be taken seriously. Perhaps there is a real God who is mediated through religious belief and practice. Adherents certainly believe so, and it makes a fundamental difference to their lives and practices. There is no point, then, in air- brushing out, or shredding the central most important thing that people subjectively think about their own beliefs, namely that they are true and that they correspond with reality [31]. Understood thus, religions are systems for responding to the reality of the transcendent. They provide access and means to ultimate reality and should be respected as such. Any attempt to reduce them to secular analytic categories of function is misguided as it misses out on what is an important and distinctive part of human character, knowledge and experience, which is oriented to the transcendent [18]. St Augustine writes of God, ‘you have made us for yourself, and our heart is restless until it rests in you’ (Augustine [1], 3). If humans have an essential, transcendentally-relating dimension, this should be recognised by outsiders to religion as well as nurtured by those within. That, of course, is not to say that religions do not have social and other effects that derive from their being humanly-created institutions.

Once again, there are implications to this kind of substantive, essentialist understanding of religion for believers and those outside. While this validates the

198 Health Care Anal (2013) 21:193–207

123

believer’s experience of his/her faith and practice, it may also mean that s/he is unwilling to see it as having social and functional significance in a primary sense. While the service of the transcendent may involve serving humans, too, this is not the prime purpose of religious adherence and practice. And questions about the efficacy and benevolence/malevolence of religious adherence may be hard to ask, as has been seen recently in the case of the uncritical response of the Catholic hierarchy around the world to child abuse. The Catholic church sees itself as founded for the worship of God and conceives itself to be engaged in response to God’s benevolent reality. Thus there is a sense in which the church may not find it easy to see itself as capable of doing or sanctioning inadvertent harm to humans [25]. This may then baffle and obstruct social and health care managers and policy makers who do not themselves share a religious faith. If they cannot see the importance of the reality and service of the transcendent, they may be puzzled that religious people do not want to become an obedient part of the ‘big society’, behaving like compliant members of other, secular voluntary organisations. Indeed, they may be appalled that religious groups are complicit with or apparently untroubled by social ills committed in and by their own members.

The question of how religion is defined and understood is an enormous one. What is and is not a ‘real’, ‘legitimate’ religion can easily become contested, as the case of Scientology illustrates [3]. Less controversially and more mundanely, some Pagans, Wiccans and others wonder why their kind of adherence is not regarded as ‘proper’ religion in public institutions so their needs are met [28]. Thus, confusion and arbitrariness about definitions and understandings of religion have important implications for how religious communities relate with health care and policy making as we have seen.

The Meanings of Spirituality

No less controversial, and perhaps more protean, is the quest to understand spirituality [27]. Spirituality was not a concept in wide usage before the 1960s, but with the advent of secularising tendencies whereby traditional majority religious communities have lost their influence on individuals and social institutions, it has become much more important as a way of talking about the non-physical, non- material needs of people in general, and in a variety of contexts from business to health care [4, 32, 33]. Often, understandings of spirituality focus on people’s needs for meaning making, belonging, finding depth in life, and pursuing some rather unspecified notion of the ‘beyond’ or transcendent [18, 37, 38].

The discourse of spirituality recognises that people have non-material personal needs and interests without implying that they need to express these in terms of formal religious adherence or belief. Thus the need to believe in a God or to belong to a community of particular practices and disciplines that may be regarded as narrow, arbitrary or unacceptable is dispensed with; each individual can choose and be helped to pursue his or her own way.

Within that overall context of the acceptance of non-material, difficult-to-define needs for meaning, purpose, belonging etc., some will chose a formal religious path. But the assumption is that all people potentially have these kinds of spiritual needs,

Health Care Anal (2013) 21:193–207 199

123

and religion might then just be one (probably minority) way of pursuing them. Thus religion in general (e.g., Christianity) and divisions within particular religions (e.g., Catholicism, Methodism) become sub-divisions of the realm of the spiritual where specific needs for, e.g., prayer, liturgy, can be met by religious communities and functionaries such as authorised ministers.

This move towards subordinating religious needs and preferences within the overall ambit of the spiritual, a realm that is universal and open to all, whatever their beliefs and preferences, is deeply compatible with a certain kind of multi-cultural secularism; it has led to a number of chaplains and chaplaincies within health care to rename themselves as spiritual care providers within spiritual care departments [36]. Some suspect that ‘spirituality’ and ‘spiritual care’ are simply ‘religion-lite’, i.e. religion with the difficult and demanding bits about believing in God and obediently undertaking communally-defined duties and disciplines removed to enable the quest for individual self-realisation and choice and to enable public money to continue to be spent on chaplains [4, 22]. Others see spirituality as having almost nothing to do with religion and being more compatible with a philosophical or therapeutic view of the self that is sympathetic to individualised, consumer secular society [26]. But almost all would acknowledge that the nature of the spiritual dimension, and whether it is essential to all persons everywhere, is a matter of debate. While some try to define spirituality concretely and specifically so that it can be directly addressed by specific interventions and behaviours, others maintain that it is, at the very least, a socially constructed notion with no universal, essential basis within the person [4].

Here, again, there are practical implications for health care. If spirituality is regarded as universally essential, and spiritual needs are the kinds of things that can be clearly identified, measured and met, then it is theoretically possible to ensure that universal spiritual care is provided for all who need it, almost whether they want it or not [30]. However, if spirituality is a construct that is differently construed amongst different people and in different contexts, then it will be much harder to agree on and to resource responses to ‘spiritual needs’. By contrast, religious needs may then be much easier to identify because consciously practising believers know what they should have and can ensure they ask for it, whereas those with no religious belonging or training may not be able to articulate their quest and their needs.

There are issues of equality and justice here. Is it right that overtly religious people should get more of a particular kind of care just because they are more visible than those whose spirituality is less articulate, less communally-based, more fragmented, and more personal and internal? If the implication of this argument were pursued, it might be suggested that the ordinary but only implicitly ‘spiritual’ person is less likely to have their needs identified and met, e.g., by chaplains and health care staff, than the overtly religious person (the vast majority of chaplains being representatives of, and products of, religious communities) who is therefore receiving an unfair advantage in health care provision perhaps [22]? If the notion of spirituality is that it is a social construction then all kinds of spiritual care, including religious spiritual care, become somewhat marginal and enter the realm of personal preference rather than concrete universal health need.

200 Health Care Anal (2013) 21:193–207

123

Some other obvious issues can be mentioned here. First, who decides what a spiritual need is and how? If individuals do not identify with this word as a descriptor of their experience, does that mean that they are somehow ignorant, or perhaps lacking in an essential aspect of human make-up due, possibly, to some genetic defect? Secondly, if spirituality is universal and ‘good for you’ is there any sense in which health care users should be required to recognise and work at it in order to increase health benefits and diminish the call on the public purse for treatment? As with the definition of religion, questions like these throw into relief the importance of unpacking concepts and the realities that they are deemed to denote if the complex relationship between religion, spirituality and health care policy, provision and experience is to be fully appreciated.

The point about all this definitional confusion and ‘play’ is not to obfuscate, but rather to lay out the real lack of clarity that underlies understandings of faith, religion and spirituality at a theoretical level. The theoretical confusions outlined reflect the practical pluralism and variety of experience and reality. There is no point in trying to pretend that there are clear definitions and understandings of these important terms if in fact they are pluralistic, contested, confused, under-determined and somewhat opaque. It is not surprising, then, that health care managers and clinicians may find it difficult to understand religion, to define religious and spiritual needs, and then to meet them.

At the general and theoretical level, it is difficult to define and delimit religion and spirituality and therefore to provide coherent responses to religious and spiritual needs. This theoretical difficulty is compounded when one considers the more practical level of dealing with particular religious groups and individuals. Here there is to be found an equal, if not greater, amount of variety and pluralism. In the next part of the paper, I will raise some of the critical points and questions that which can make dealing with such groups and individuals problematic and complex.

For the most part, I here part company with thinking about spirituality and spiritual needs as on the whole these are generally regarded as more personal and individual than corporate. However, depending on understandings of spirituality and spiritual needs, some of the same issues and problems may pertain.

Practical Issues and Considerations in Dealing with Religious Groups and Individuals

In this part of the paper, I want briefly to allude to some of the more practical misconceptions and assumptions that need to be taken into account in approaching and understanding overtly religious groups and communities.

Not All Religious Groups are the Same

There is a tendency in British society to assume that just because social groups are designated as ‘religious’ that they will basically have a great deal in common in terms of belief, organisation and structure. This tendency has been manifested recently in the Government’s apparent desire to find Islamic equivalents to the

Health Care Anal (2013) 21:193–207 201

123

Archbishop of Canterbury or the Chief Rabbi to speak on behalf of Muslims in the same way that the latter luminaries are held by some to speak with authority on behalf of Judaism or Christianity. Religious traditions and groups vary enormously in their structures and organisations. Muslims, like Quakers, have no formal leaders and authority is diffused through a web of scholars. Neither Islam nor Quakers have central policy making apparatuses or paid professional leaders—the Imam in the local mosque is not the same as an Anglican vicar, neither are either quite like a Buddhist chaplain. This means that it may be very difficult for health care workers and policy makers to identify who they should consult with in different religious groups and what authority and representativeness they should concede to those consulted. For example, many charismatic Christians in independent churches would not see the Archbishop of Canterbury as necessarily speaking for them in health care matters and a local clergyman may be similarly distant from many of the Christian communities in his own area.

On a related point, there are, of course, some very tiny religious communities in the UK, Quakers, Unitarians and Shintoists being cases in point. The question then arises, are they to be ignored because they are small, or is their smallness and relative weakness in making their voice and opinion heard a reason to take more care in consulting them and meeting their self-designated needs?

Religious Communities are Internally Pluriform and Diverse

There is no such thing as the Muslim, the Jewish, or the Buddhist view on any matter. Within major religious traditions like these there will often be a plurality of belief and practice—the divisions between Catholics and Protestants in Christianity being one example, then that between Sunni and Shi’i Muslims being another at a macro level. More locally, communities sub-divide further—Protestants, for example, can be Methodist or Independent Charismatic. And they are likely to belong to different local communities that have their own ways of thinking and working even if they are situated within some kind of ‘denomination’ [11]. Here again, this complexifies the matter of consultation and meeting spiritual or religious needs. A Catholic may want easy access to sacraments as a priority, while an independent Protestant might most value a Bible and a prayer. Some Christians might believe in the possibility of direct divine healing in response to prayer, while others are more likely to see health and healing as coming through secular medical means [24]. There are liberal and traditionalist Christians as there are liberal and traditionalist Jews. They might, both locally and nationally, have very different views and opinions on religious and spiritual needs, but also about health care policy and delivery, e.g., of a woman’s right to choose an abortion.

Not All Religious Individuals Relate to Their Religions in the Same Way

Just because someone admits to a religious adherence this does not necessarily mean that their commitment is keen and knowledgeable. There are degrees of belonging and believing and this may also affect the ways in which ‘religious’ people react to and make demands upon health care. Religion may be taken as a marker of

202 Health Care Anal (2013) 21:193–207

123

communal or ethnic origin in some contexts, so that, for example, many people in the UK would see themselves as nominal but non-participant Christians due to upbringing or schooling. Their view of their religion and its implications may be very different from that of very committed people. So, for example, it seems likely that many nominal Christians are much less exercised about sexual mores and homosexuality than their committed counterparts. By the same token there can be a good deal of difference between what ordinary or nominal religious adherents think and want and what their leaders say they want. In some religious groups, leaders tend to be more conservative than their followers, e.g., in public, Catholic leaders will usually condemn the use of birth control, while their followers may be less keen to promulgate this view. In others, leaders may be more progressive than their lay followers.

Ignoring the Big Picture

For committed religious adherents their religion denotes what is unquestionably real and important—the ‘really real’ [15]. For Jews, Christians and Muslims, for example, it is the one God of monotheism who is uniquely real and important and their lives are spent in the worship and service of this God whose will is sought in all aspects of life, however mundane. This is a kind of radical, altruistic and obedient monotheism that is difficult for some to understand in a society that values consumer choice and the pursuit of personal happiness for its own sake. But for believers, this is what enables the world and their lives to make sense and it is within this context that they will make decisions about their life and health. Life, happiness and health may, then, be radically subordinated to religious belief and obedience.

This can be difficult for health care workers to understand because they miss out on seeing the big, religious picture in which religious believers situate their lives; this has its own ends and rewards. It is within this larger context that religious believers enact ritual observances such as special dietary and funeral practices. Often, these practices that support and exemplify commitment and belief are, however, taken by non-religious people as the most important aspects of what it means to be a believer. The subordinate and external is mistaken for the final end and vision; believers’ behaviour can then be interpreted as unnecessarily difficult. In practice, it may in fact be so within a health care context. But most major religions actually see inner attitudes and an orientation to loving God and other humans as the main point of their religions. In that context, many believers are far more flexible than some outsiders might think. For example, some Muslim chaplains will shake hands with (mostly unaware non-Muslim) members of the other sex if they think that not doing so will give the impression that they are unfriendly or rejecting [12]. They do not want to give the impression that their religion or God is stand-offish or unfriendly and so will subordinate very important ritual observances and disciplines to more important theological and religious truths. This bigger vision and picture must be recognised in contacts between health care and religious groups and communities. Religion is not about mindless scrupulosity, but about having a large picture of the world and human flourishing that is expressed partly in daily

Health Care Anal (2013) 21:193–207 203

123

behaviours and practices. But the part should not be mistaken for the whole so that religious people are regarded as preoccupied with minute trivialities.

Understanding Religious Views of Health and Health Care

Religions provide a comprehensive, inhabited world view in which their adherents understand all aspects of their life, including health, illness and wellbeing in terms of their relationship to what is ultimately real, which they might call God or the transcendent. This gives believers a different end and understanding of what life is for. Often, religious beliefs and practices are deeply compatible with those of the health care system—the relief of suffering and pain and helping those who are ill or in need, for example, is supported by most major religions. However, there can be points of difference and resistance in religious world views and practices and these are often not recognised or valued in secular health care [39].

The health care system has its own uniquely real and unquestionable faith system. This includes the idea that all pain and suffering are meaningless and that death is the worst thing that can happen to someone [39]. This kind of belief system then can come into real conflict with more overtly religious traditions where people may see suffering and death as part of the divine providence which is to be gladly learned from and endured as the will of the divine, not just as something to be eliminated at all costs. What I am trying to say here is that religious traditions and communities, because of their teleologies and beliefs, may not always be compatible with the secular ideology and ‘religion’ of health. Indeed, both individual believers and religious communities may be sources of resistance and contradiction to the assumptions and beliefs of secular health care institutions. There is, then, a sense in which if religion is to be taken seriously, it cannot just be a matter of exploiting the humanistic good will of religious communities while ignoring or trying to change the bits that inconveniently don’t fit in (we can use the mosque to deliver general health promotion—what a shame that they don’t want us to do sex education there). What is required is a kind of ‘inter-religious’ dialogue about health, health care and illness, that involves not just religious communities talking to each other (they, too, have different views) but discussion with the religion and religious community of health care so that there is real learning between the parties concerned. Maybe the health care community and institutions have something to learn here. For members of religious communities, their beliefs and practices are not just some kind of private ideology, they believe that they are great public importance in understanding all aspects of the world. This may challenge the hegemony of Western individualistic biomedicine, perhaps for the better of all concerned.

The Ubiquity of Religion in Health Care

Often, people talk about religion as if it were a complete external to health care institutions that comes into those institutions when the patients arrive and declare themselves to be members of a particular religious group as they are clerked in. However, many health care staff are active members of faith communities; their

204 Health Care Anal (2013) 21:193–207

123

faith may form an important part of their motivation and personal support system for doing the job that they do.

It is probable that the NHS is a considerable beneficiary of religious communities, not only in the workers it provides to health care, but also in the collaboration which they are prepared to provide in the community, both formal and informal. It is a mistake to think that religion is an external to health care provision and delivery. It is there, implicitly and explicitly, at many points, as a resource and sometimes a challenge. The choice is whether to recognise and work constructively and critically with it, or whether to ignore it and hope that somehow its presence and influence can be downplayed or even diminished.

Conclusion

In this paper, I have sought to raise, in a preliminary way, some basic issues about understanding religion, religions and spirituality in health care with a view to enabling a more critical mutual engagement and dialogue to take place between health care institutions and religious communities and believers. There may be, perhaps, a tendency in a secular society that formally ‘doesn’t do God’ to stereotype religion and religious people as demanding, inconvenient ‘customers’ of health care institutions or as sources of free labour and delivery of secularly-defined social and health benefits [35]. To counter this, I have tried to show that understanding religions and religious people is a complex, interesting matter. Taking into account the whole reality of religion is not just a matter of meeting specific needs at the bedside, nor of trying to ensure that religious people abandon their distinctive beliefs and insights when they engage with health care institutions and policies, ‘converting’, perhaps, to the beliefs and practices of individualistic secular biomedicine. What is required is a more subtle, thoughtful approach that benefits both the religious and health care communities. Religion, however understood, is not an accidental external either in society or in health care. Many health care institutions and practices find their roots in religious communities and traditions. It is possible to see the NHS itself as the culmination of a project to create a shared, common, public religion [40]. Members of the distinctive religious communities that are once again coming into focus with the decline of the shared secularlised vision of the NHS form an important, integral part of the structure and fabric of health care delivery, whether as users or in paid or voluntary delivery capacities. Religion, here as in other parts of human life, is both facilitator and resistor, friend and critic, for health care institutions, providers and workers. Partnership is thus more difficult, more challenging, and potentially more fruitful than it is often conceived to be.

In conclusion, let me emphasise again that this notion of mutual understanding and engagement is not one way; it is not simply down to health care institutions to learn more about the nature of religion, spirituality and religious communities. There is clearly much ignorance, some of it wilful, in religious communities about the nature, aims and benefits of formal health care organisation and delivery; this is a matter that religious communities themselves need to address more energetically.

Health Care Anal (2013) 21:193–207 205

123

However, it would take another paper to begin to explore the difficulties and prejudices that religious groups bring to health care institutions. The way forward here for all parties is more dialogue, as well as, where possible, more collaboration and co-operation to address together the universal problems of illness, suffering and death and the needs of those who find themselves living in their shadow.

References

1. Augustine, St. (1991). Confessions. Oxford: Oxford University Press. 2. Bailey, E. (1999). Implicit religion: An introduction. London: Middlesex University Press. 3. Beit-Hallahmi, B. (2003). Scientology: Religion or racket? Marburg Journal of Religion, 8, 1–11. 4. Carrette, J., & King, R. (2005). Selling spirituality: The silent takeover of religion. Abingdon:

Routledge. 5. Cobb, M., & Robshaw, V. (Eds.). (1998). The spiritual challenge of health care. Edinburgh:

Churchill Livingstone. 6. Davie, G. (1995). Religion in Britain since 1945: Believing not belonging. Oxford: Blackwell. 7. Department of Health. (1991). The patient’s charter. London: Department of Health. 8. Fitzgerald, T. (2000). The ideology of religious studies. New York: Oxford University Press. 9. Flanagan, K., & Jupp, P. (Eds.). (2007). A sociology of spirituality. Farnham: Ashgate.

10. Ford, D. (1999). Theology: A very short introduction. Oxford: Oxford University Press. 11. Fulkerson, M. M. (2007). Places of redemption: Theology for a worldly church. New York: Oxford

University Press. 12. Gilliat Ray, S., Ali, M., & Pattison, S. (2013). Understanding Muslim chaplaincy. Farnham: Ashgate. 13. Granshaw, L., & Porter, R. (Eds.). (1989). The hospital in history. London: Routledge. 14. Hart, D. G. (1999). The university gets religion: Religious studies in American higher education.

Baltimore: The Johns Hopkins University Press. 15. Hick, J. (1989). An interpretation of religion. Basingstoke: Macmillan. 16. Jacobson, H. (1994). Roots schmoots: Journeys among Jews. London: Penguin Books. 17. Latour, B., & Weibel, P. (Eds.). (2002). Iconoclash: Beyond the image wars in science, religion, and

art. Cambridge, MA: MIT Press. 18. Lynch, G. (2007). An introduction to progressive belief in the twenty-first century. London: I B

Tauris. 19. Orchard, H. (Ed.). (2001). Spirituality in health care contexts. London: Jessica Kingsley. 20. Orsi, R. (2005). Between heaven and earth: The religious worlds people make and the scholars who

study them. Princeton: Princeton University Press. 21. Paden, W. (2003). Interpreting the sacred: Ways of viewing religion. Boston: Beacon Press. 22. Paley, J. (2008). Spirituality and nursing: A reductionist approach. Nursing Philosophy, 9, 3–18. 23. Pals, D. (1996). Seven theories of religion. New York: Oxford University Press. 24. Pattison, S. (1989). Alive and kicking: Towards a practical theology of illness and healing. London:

SCM Press. 25. Pattison, S. (2000). Shame: Theory, therapy, theology. Cambridge: Cambridge University Press. 26. Pattison, S. (2001). Dumbing down the spirit. In H. Orchard (Ed.), Spirituality in health care contexts

(pp. 33–46). London: Jessica Kingsley. 27. Pattison, S. (2010). Spirituality and spiritual care made simple: A suggestive, normative, and

essentialist approach. Practical Theology, 3, 351–366. 28. Pearson, J. (Ed.). (2002). Belief beyond boundaries: Wicca, celtic spirituality and the new age.

Farnham: Ashgate. 29. Porterfield, A. (2005). Healing in the history of Christianity. New York: Oxford University Press. 30. Reed, P. (1998). The re-enchantment of health care: A paradigm of spirituality. In M. Cobb & V.

Robshaw (Eds.), The spiritual challenge of health care (pp. 35–55). Edinburgh: Churchill Livingstone.

31. Robinson, M. (2010). Absence of mind. New Haven: Yale University Press. 32. Sheldrake, P. (2007). A brief history of spirituality. Oxford: Blackwell Publishing.

206 Health Care Anal (2013) 21:193–207

123

33. Sheldrake, P. (2010). Spirituality and healthcare. Practical Theology, 3, 367–379. 34. Smith, G. (2008). A short history of secularism. London: I B Tauris. 35. Spencer, N. (2006). Doing God: A future for faith in the public square. London: Theos. 36. Swift, C. (2009). Hospital chaplaincy in the twenty-first century: The crisis of spiritual care in the

NHS. Farnham: Ashgate. 37. Swinton, J., & Pattison, S. (2010). Moving beyond clarity: Towards a thin, vague and useful

understanding of spirituality in nursing care. Nursing Philosophy, 11, 226–237. 38. Taylor, C. (2007). A secular age. Cambridge, MA: Harvard University Press. 39. Wilson, M. (1975). Health is for people. London: Darton, Longman and Todd. 40. Woodhead, L., & Catto, R. (Eds.). (2012). Religion and change in modern Britain. Abingdon:

Routledge.

Health Care Anal (2013) 21:193–207 207

123

Copyright of Health Care Analysis is the property of Springer Science & Business Media B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.