Spirituality and Medicine: Friends or Foes?
Christian Steineck, Bonn University, Institute for Contemporary Japanese Studies
(Paper delivered at the IAHR World Congress, March 24-31 2005, Tokyo; Panel:
Medicine and Spirituality)
Introduction
In February 2000, we had a meeting of scholars from various disciplines at Bochum
University, a somewhat depressing example of 1960s "rational architecture". Our aim
was to plan a interdisciplinary research group on "Cross-cultural Bioethics". The group
included specialists in regional studies, such as sinologists or japanologists, experts in
the history and doctrine of religions, such as islam, christianity, and buddhism,
philosophers, medical scientists, biologists, and clinicians. In a general discussion on
the problems of modern medicine, one participant, a clinical neurologist, asked
something that was obviously troubling him beyond purely academic interest: "Why do
people hate us so much?"
His question has stayed with me. The success of modern medicine seems very evident.
It creates hope for millions of people who, only a century ago, might have died of
afflictions that are now routinely prevented or cured. Advanced biomedical research
explores therapies for other diseases that did not even have a name 150 years ago. The
public around the globe wants these therapies. Citizens and scientists unite in their
dismissal of intellectuals who bother them with the ethical niceties concerning research
and production of such cures. The costs of health insurance plans continue to rise, as
everyone seizes their opportunity to benefit from the growing human ability to cure
illness, to prevent disease, to maintain and restore health.
At the same time, within the same societies, and even with the same people, there is an
evident dissatisfaction and frustration with this very medicine. There is even contempt
and hatred for medical professionals. And bookstores and public libraries sometimes
seem to hold more popular books on "alternative medicine" than information on the
standard science of the human body and its afflictions.
Why this is so, is a multi-faceted question, and I will not even try to give a
comprehensive answer within the limited scope of this paper. Let me only mention in
passing an answer given by Ivan Illich: He warned that modern medicine in its specific
form of social organisation deprives individuals of their competence to live their own
lives and care for themselves.1 Anyone who has been "absorbed" by a medical
institution and sent from one specialist to another without being told what's going on,
will immediately understand the problem behind Illich's claim. Such problems prevail in
spite of institutions like "informed consent", which are meant to safeguard the
participation of the afflicted individual in therapeutic decisions.
In the light of Illich's thesis, one may argue that many of the "alternative therapies"
seem to place more competence in the hand of the patient. They often provide for
"personal" explanations and solutions to a given health problem. But not all of them do,
and anyone who has met with firm believers in one or another alternative method will
easily doubt whether these do indeed increase the competence and independence of
their adherents.
Be that as it may, my main question in the following will be, whether there is a
necessary conflict between modern medicine and "spirituality". This questions derives
from the assumption that part of the frustration with modern medicine is due to the fact
that it leaves vital questions, and needs, unanswered. I presume that this is partly behind
the craving for alternative therapies with a more "spirtual" air. Now, are modern
medicine and "spirituality" mutually exclusive? My answer, as befits that of a
philosopher, will be a theoretical one, and I will base it on some elements of Ernst
Cassirer's Philosophy of Symbolic Forms.
Definitions
Let me start by giving some initial definitions and explanations, to delineate our field of
concern.
We all know modern medicine by experience. Although it currently is set to expand its
field of competence "beyond therapy",2 like all healing arts, it is first and foremost
concerned with restoring life functions that have been impaired through accidents,
diseases or other causes. Maintaining and stabilizing these functions, and preventing
impairments, are additional tasks. However, not all acts of or knowledge concerning
these fundamental tasks qualify as medicine. The defining specification is that medicine
employs a theory to explain the life functions, their impairments, and the possible kinds
of cures. Modern medicine is additionally characterized by the fact that the theory
1
2
Illich, Ivan: Limits to Medicine : Medical nemesis : the Expropriation of Health. Harmondsworth New
York : Penguin, 1977
The U.S. President's Council on Bioethics: Beyond Therapy: Biotechnology and the Pursuit of
Happiness. New York: Harper Collins, 2003.
behind it is based on an experiential science of physical nature that seeks to establish
"laws of nature" which can be expressed in quantitative relations. Its "Formideal", its
preferred telos of expression, is one informed by mathematical operations. Its diagnostic
methods, therefore, are analytical and directed towards "objective" measurements of
biophysical or biochemical quantities. Its cures are of a technical nature, and designed
to correct the "balance sheet" of the afflicted body.
Defining spirituality is a bit more difficult. Most definitions can be described as
material and rich, which means that they are also imbued with tenets of a specific
weltanschauung. I'll start with some examples and proceed towards a more modest and
functional formulation.
The Latin term "spiritualitas" has been used in Christian Latin since the 5th century to
describe the attitude a religious person should cultivate: to care for one's soul and its
progress in its relationship with god, to attend to spiritual needs instead of craving for
carnal pleasures, etc. The term gradually lost importance in early modernity, only to be
revived in the 20th century. The need for "spirituality" or "spiritualité" was now
emphasized by some in contradistinction to Church ritual, theological doctrine or
codified ethical rules. In this context, it pointed toward personal religious experience
and, once again, the relationship between the individual Christian believer and her god,
or, as one source had it: "the perfection in Christendom and the ways leading towards
it".3
A second example: Suzuki Daisetz in his work on Japanese Spirituality gave a different,
but equally "rich" definition of the term. To him, spirituality related to an awakening to
the fundamental unity he perceived as envelopping the mental and the material, and
other dichotomies that characterize secular consciousness. He interpreted this
awakening as the self-realization of a fundamental faculty, or power, operating within
the individual, i.e., the spirit, as opposed to the faculty of reason. Reason produced
knowledge through by analytical differentiation, and such knowledge was inherently
dualistic. The awakening to the self-awareness of the spirit led to wisdom — or
spirituality —, a perception of unity behind, or within, all oppositions defined by
reason.4
It is evident that such definitions of spirituality must lead to a perception of opposition
3
4
Ritter, Joachim u. Gründer, Karlfried (Hg.): Historisches Wörterbuch der Philosophie, Vol. 9: Article:
"Spiritualität". Basel: Schwabe, 1995, pp. 1415-1422, here: 1415-1418, 1422. The literal quote is
from: Pourrat, Pierre: La spiritualité chrétienne, Vol. 1, Paris: Gabalda, 1921, p. V.
Suzuki Daisetz: Nihonteki reisei. Tokyo: Iwanami, 1943, pp. 16-18. (English: Japanese Spirituality;
translated by Norman Waddell. New York : Greenwood Press, 1988.)
between science, and therefore, modern medicine, and spirituality. Scientific methods
and modes of thinking require an unlimited openness of horizons. The relentless
questioning of every "given" fundamental, the establishment of "doubt" as a central
methodical operation, both seminal features of scientific thinking, run contrary to the
very mode of thought required by the Christian religion, which is a religion defining
itself through a confession of belief in an absolute, i.e., God. Likewise, scientific
methods may allow for a synthesizing of "opposites". What they do not allow for, is a
"unity of all oppositions", as this would include contradictions. Rational thought does
not condone such a unity of contradictions. The simple reason is that no notional
meaning can be established once a contradictory statement is accepted. Suzuki's
"wisdom", on the level of theory, resembles what Shakespeare's Macbeth says about
life: "a tale, told by an idiot, full of sound and fury, signifying nothing." Thirdly, every
understanding of spirituality that is defined by the assumption of a seperate "spiritual"
layer of reality, to which no laws of nature would apply, contradicts the idea of unity
that informs every rational approach to knowledge. Science has long accepted that
reality is "rich" and requires a plurality of methods to explore its various dimensions.
But it has never forgone the idea that these various methods do explore a single reality
and that there must be a continuity between the various regularities established.
But this need not be the end of our story. Let us start again by using a less "rich", more
formal definition of "spirituality". There are common elements shared by the above
named definitions. One is an emphasis on realization within or through the individual.
Another consists in relating this individual to "something greater" that transcends the
confines of her life. Taking these together, spirituality would then denote an attitude, or
mode of experience, in which an individual relates her life, or events in her life, to
something beyond the confines of her own limited perspective on the world. This
relationship is supposed to give the individual life, or some event within it, its meaning.
One may characterize spirituality as a subset of attitudes within the sphere of possible
general attitudes toward human existence. Its complementary opposite would be
nihilism, the belief that all life and action is ultimately meaningless. Its negation would
be a-spirituality, an attitude that is blind to, or consciously refuses to ask, questions that
transcend the realm of clearly defined individual problems and tasks. "Positivism", as
an attitude toward life, vividly described in Max Frisch's novel "Homo Faber", would
be a theoretical formulation of an a-spiritual world-view.5
5
Frisch, Max: Homo Faber: Ein Bericht. Frankfurt a. M.: Suhrkamp, 2001. English: Homo Faber :A
Report ; translated from the German by Michael Bullock. San Diego : Harcourt Brace, 1994.
We can further differentiate between various kinds of spirituality. Religious spirituality
may be defined by a culturally established concept of that "greater something" to which
the individual relates his life, and by social institutions that foster and shape this
relation. An alternative is existentialist spirituality, spirituality based on an individual
decision to choose or define this "greater something" for oneself. Still another
perspective — we might call it 'critical' or 'reflective' spirituality — would carefully
stress the provisional character of all descriptions and identifications in this respect, and
even of the spiritual perspective in itself.
Theoretical Evaluation: Background
Before proceeding to an evaluation of our problem – the relationship between modern,
scientifically informed medicine, and spirituality — let me briefly summarize some
basic tenets of Cassirer's approach, which I want to apply to our problem. Five basic
hypotheses characterize the Philosophy of Symbolic Forms:6
1) Reality can be understood properly only if considered in its relation to those
mental / cultural methods through which it is objectified. The reason is that "reality"
itself is a category, i.e. a mental instrument by which we distinguish what is "real", that
is, not just the working of our mind, from that, which is unreal, that is, either
nonexistent or a mere mental fabrication.
2) All relevant mental and cultural methods have to be taken into consideration in
order to achieve a full understanding of reality.
3) These diverse methods or ways of objectification, such as science, art, religion
or technology, are irreducible - they cannot be fully explained in terms of one another,
because each of them objectifies a different dimension of meaning. Art can be an object
of science, as science can be an object of art, but neither can art replace science, nor can
science do the job of art.
4) The notion of the "symbolic function" helps to understand the unity inherent in
this diversity of methods. At the same time, it serves to overcome metaphysical
misconceptions such as materialism, idealism or dualism, because all symbols are
media, which realize intellectual or spiritual content in material form, while at the same
time making it possible to apprehend their difference.
5) There are three fundamental levels of symbolic functioning: Expression,
6
Cassirer, Ernst: Philosophie der symbolischen Formen. 3 vols. Darmstadt: Wissenschaftliche
Buchgesellschaft, 1964. English: The philosophy of Symbolic Forms; translated by Ralph Manheim.
Pref. and introd. by Charles W. Hendel. New Haven: Yale University Press, 1953-1996.
representation, and notional meaning. They are ordered in a "nested hierarchy", that is,
the higher ones unfold within the lower ones at once remaining dependent on them and
transcending their constrictions. Science, which is one of the symbolic forms that
employ the function of pure meaning, is coined in language, the classical locus of
representation, which itself makes use of expression. Expression and representation are
indisposable for the functioning of science, but scientific theories are structured
according to laws that transcend the specific constrictures limiting representation and
language.]
Theoretical Evaluation
How does modern medicine relate to spirituality? Most relevant to our question is
Cassirer's distinction of three fundamental levels of symbolic functioning, which are
explained through the analysis of those symbolic forms in which they are most clearly
expressed. To Cassirer, myth is the cultural manifestation most closely connected to
expression. Language exemplifies representation, and science, notional meaning. There
is a hierarchy of abstraction and objectivity. Expression is tied to a given situation and a
singular action, carrying a meaning which cannot be exactly reproduced. Representation
allows for an identification of meaning and objects beyond a given situation, but
remains connected to the forms of perception and intuition. Notional meaning can
transcend the confines of perceptual experience and intuition and produce objects that
are constituted purely by a system of symbolic relations.
There is also a converse hierarchy of materiality and subjectivity. The meaning
conveyed by expression is richly informed by its actual form and perceptional
characteristics. Every detail is of importance. On the other hand, beyond the level of
conventional gestures, expression is highly indeterminate. Everything bears an air of
meaning, but just what it is, remains dependent on the situation and the people involved.
Therefore, a high level of subjective attunement is necessary for successful
communication. On the other hand, if an understanding is accomplished in this manner,
there is an equally high degree of satisfaction.
Language allows us to speak in a more clearly defined manner. The world of language
is the world of "things" and "essences", fixed entities with a characteristic set of
properties. In the world of expression, you can never step into the same river twice. In
the world of language, you can. "Things" and "essences" can be isolated from the
momentary changes in the environment, from the actual relations in which they are
encountered. Within the semantics of language, the denotation of a phrase can be
seperated from its connotations. That is a great achievement, which also leads to greater
flexibility in communication: Language can be rephrased, translated etc., opening up
new ways to communicate meaning beyond interpersonal attunement. However, this
corresponds to a greater distance between both the speaker and his words, and the
speaker and the listener. Words may fail both of them, especially on an emotional level,
unless, in expressional or poetic language, the speaker skilfully employs the sensual,
formal and material aspects of language in an expressional manner.
This distance is exarcebated on the level of notional meaning. Here, within the world of
mathematics and science, we are in a dimension of purely relational meaning, which
utterly transforms all material elements of a given situation. Whether Newton's famous
apple was red or green, whether it tasted good or bad, whether the tree belonged to his
beloved grandmother or a disreputed aristocrat, is of no importance when it enters
gravitational equations. For that matter, it might have been a pear, or even a piece of
manure. Again, this is a great achievement, because it allows us to establish a world of
constant relations, a "method" where our ears and eyes may perceive only "madness".
To come back to the realm of medicine, it allows us to study fruit flies, sheep and rats,
and learn about causes of illness and possible cures for human beings. Once again, we
pay for this by a methodical disregard for certain aspects of a given situation, which
may be pertinent, or even essential, on the level of expressional or verbal
communication.
And this is what we find in modern medicine: It is characterized by its scientific
methods and contents. In the framework of symbolic forms and functions, it is largely a
realization or application of the function of notional meaning. As such, its treatment of
sensual and perceptual experience is necessarily characterized by a certain disregard for
their singular aspects. Sensual experience is treated as an exemplary case of a general
class of events. It undergoes, as Cassirer once put it, a "transsubstantiation", which robs
it of its rich and colourful garment and turns it into an abstract element in a serial causal
relation.7 Moreover, in differiential diagnostics, a single experience may be dissolved
into multiple elements of various relations. The advantages of such procedure are
evident: they allow for the identification of various ways of highly effective
manipulation, in order to restore the proper functions of the body.
But even if all elements of diagnostic analyses are later reintegrated into a single
therapeutic strategy, something has obviously been lost on the way. Scientific analysis,
7
Cassirer: Philosophie der symbolischen Formen III, p..510; Marx, Wolfgang: Philosophische
Letztbegründung als Selbstbegründung des reinen Denkens in 'reiner' Erkenntnis. In: Wolfgang Marx
and Ernst Wolfgang Orth (ed.): Hermann Cohen und die Erkenntnistheorie. Würzburg: Königshausen
& Neumann, 2001, pp. 123-134, here: p. 126.
by transforming experience into elements of various equations, isolates single,
measurable aspects of what initially is a "total" human experience, and severs the ties
that integrate them into the singular horizon of an individual life. To be sure, this is a
legitimate strategy to enable efficient action. In a way, it is also a necessary condition of
medical therapy. But it is equally true that, to the afflicted individual, his sickness is an
event within the horizon of his own, singular life. It is, first and foremost, an
"existential" problem. It stands in relation to things he has to do, wants to do, hopes for
or fears. It bears an influence, however weak it may be, on his job, his family life, his
personal and social relationships. He may want to be alert, but now he feels drowsy. He
may want to look good, but now there are these red spots on his skin. He may want to
be kind, but a headache makes him irritable. Or, he may feel stressed, and his sickness
gives him an opportunity to rest. He can make excuses to people he does not want to
meet. He may express his anger and apologize, because he's irritated by pain. In any
case, his condition will acquire a meaning within the horizon of his life. Just what
meaning it is going to be, he will have to find out, as a part of his coping with his
illness.
Obviously, modern medicine can be of little help in that respect. But that does not mean
that the search for meaning is in itself an irrational one. It is legitimate, and even
necessary, especially if the affliction is not trivial, but serious or even catastrophic.
However, there can be no 'objective solution', because the task defies a strategy that
would once again subsume the event under an abstract rule.
This can also be a problem of a doctrinal, religious reaction to the problem of a given
illness or affliction. Religious doctrines belong to the world of language. They
formulate an essence of certain sets of typical situations. This essence is, of necessity,
abstracted from the individual and the concrete horizon of a singular life and its equally
singular events. Relating such an event, especially a potentially catastrophic one, to a
standard religious interpretation may be helpful, but certainly not if the interpretation is
imposed on the individual in question. If there is a religious answer to such a problem, it
has to be a 'spiritual' one, in the sense defined above, one that creates a link between the
specific aspects of the individual situation and the greater vision of the given religion.
On the other hand, we should avoid narrowing the spectre of possible solutions to those
provided by religion. As our attempt to define spirituality has shown, existential
questions can be answered in various ways, religious spirituality being just one of them.
Factually, some formulations of religion or ideology may seem hard to combine with
our present knowledge of the world, and some will clash with ethical principles
established over time. But none of the principal paths commands a privilege above the
others. There is no way to prove that an a-spiritual positivism is, on principle, superior
to religious spirituality, or that existentialism is better than nihilism.
The reason for this is that existential problems are problems of expression. They can be
formulated in abstract notions, but their specific kind of "truth" demands that they be
realized, or embodied, by an individual in the given situation, and in a comprehensive
manner. Such truth can never be "objective", because it cannot be isolated from the
situation and the subject concerned. Ideally, it can prove "exemplary", if it is in line
with our knowledge of the world and well-reasoned ethical principles, and if turns out
to be a source of inspiration to other people.
Conclusion
To sum up, modern medicine has to accept that its methods describe the sphere of its
possible success as well as its limits. Human afflictions pose problems that cannot be
solved in a scientific manner. Some of them belong into a realm that has traditionally
been addressed by religion. After enlightenment, we know that no single religion can
command a position of superiority, and that human existence allows for non-religious
interpretations, which may be spiritual, or not. Each of these can be "exemplary" and
none of them "objectively true". In any case, we should accept that the way modern
medicine addresses the failing of life functions leaves a space that has to be filled. Just
how it is going to be filled, should not be regulated by any medical or other authority,
except when producing socially disruptive or harmful results.
A final remark concerns an oft quoted (but finally failed) attempt to include "spiritual
well-being" in the WHO's definition of health, which would then read: "Health is a
dynamic state of complete physical, mental, spiritual and social well-being and not
merely the absence of disease or infirmity." 8 One result of our analysis is that we better
avoid such a well-meaning enlargement of our understanding of health. As we have
seen earlier, spirituality is but one of the possible attitudes towards human existence. To
include "spiritual well-being" into the definition of health would mean to make this
attitude a norm. All other attitudes would then, by definition, qualify as "unhealthy", if
8
Proposed in 1997 by a special group of the WHO Executive Board for the review of the Constitution.
World Health Organization: Review of the Constitution... , Executional Board: Printed Matter 101/7
(1997), p.2. See also: Khayat, M.H.: Spirituality in the Definition of Health: The World Health
Organization's Point of View. (http://www.medizin-ethik.ch/publik/spirituality_definition_health.htm;
accessed 27.4.2005)
not "sick". This would not only be discriminatory against adherents of non-spiritual
outlooks on human life. It might even foster attempts to "cure" those people who do not
subscribe to a spiritual world-view, and, not less importantly, it may divert attention
from real health issues like access to clean water, malnutrition, or HIV. Thus, even if
one accepts the beneficial effects certain religious or spiritual attitudes can have on
maintaining or restoring health in an individual, it would neither seem prudent nor
rational to introduce spirituality into the very definition of health itself.