HEALING, HEALTH CARE, AND SPIRITUALITY
A Balm for Gilead: Spirituality and the Healing Arts, by
Daniel P. Sulmasy. Georgetown University Press,
Washington, DC, 2007, 160 pp., $16.95 (paper).
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Aging, Spirituality and Palliative Care, edited by
Elizabeth MacKinlay. Haworth Pastoral Press,
Binghamton, NY, 2006, 259 pp., $27.95 (paper).
The Gerontologist
In gerontology, as in any field, hot topics ebb and
flow. Although the research literature on religion,
spirituality, and health might be better described as
‘‘warm’’—due to persistent questions about scientific
merit and applicability to practice (Sloan, Bagiella, &
Powell, 1999; Sloan, Bagiella, VandeCreek, & Poulos,
2000)—it has grown steadily since the 1980s, with over
70 articles published in 2006 alone (Koenig, 2007). At
the same time, there has been increasing interest in the
role of religion and spirituality in various forms of care
for older people.
Now we have two more books to add to the collection
of works that seek to understand the connections
between transcendence and immanence realized through
physical experiences of suffering, illness, and death.
Although each has ‘‘spirituality’’ in the title, at first
glance these books seem very different. Aging, Spirituality, and Palliative Care, edited by Elizabeth
MacKinlay, is a collection of sixteen papers presented
at the 3rd International Conference on Ageing and
Spirituality, held in Australia. The conference focused
on late life spirituality and palliative care which was
interpreted broadly to include people with dementia,
and not simply those who have been ‘‘officially’’
designated as having six months or less to live. Reading
these papers, one comes to appreciate the status of
palliative care in Australia and the way it is supported
by the Australian Government Department of Health
and Ageing (see, for example, http://www.health.gov.
au/palliativecare and http://www.pallcare.org.au/).
In contrast to MacKinlay’s edited volume, Daniel P.
Sulmasy’s book, A Balm for Gilead: Spirituality and the
Healing Arts, does not explicitly address aging issues and
takes up the subject of death only in the next to last
chapter. He describes his book as a ‘‘work of spirituality,’’ a collection of ‘‘meditations’’ grounded in Catholic
theology, nurtured by fellow Franciscan friars, and lived
in his practice as a physician, professor of medicine, and
director of the Bioethics Institute of New York Medical
College (p. x). If readers mistakenly assume that a
meditation must be tranquil, the opening pages will
quickly disabuse them of that notion. Almost immediately, one comes upon powerful jeremiads about the
current state of health care in the United States; later,
those passionate cries about health care ‘‘wandering
aimlessly, surrounded by venomous vipers’’ are balanced
with quiet reflections on Biblical narratives and humble
descriptions of the fallibility of physicians (p. 61).
Similarly, Aging, Spirituality and Palliative Care
presents intimate portraits of palliative caregiving
(by Michael Barbato, David Currow and Meg Hegarty,
and Ann Harrington) and caregiver grief (Margaret
O’Connor and Susan Lee) while not shying from polemics. However, due to the fact that most of the authors
are from Scotland or Australia, there are few complaints about the current state of health care. Instead,
they critique the commodification of successful aging
(Harriet Mowat, and Bruce Rumbold), consumerist
approaches to spirituality (Ruwan Palapathwala), and
what Rosalie Hudson calls the ‘‘dumbing down’’ of spirituality by the bureaucratic language of ‘‘spiritual coping
strategies’’ and ‘‘spiritual orientation inventories’’ (p. 51).
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Like Sulmasy, MacKinlay is a health care professional (RN), professor (at the School of Theology,
Charles Sturt University), program director (Centre for
Ageing and Pastoral Studies) and a committed person
of faith (an ordained priest in the Anglican Church of
Australia). Both appreciate the blessings of the biomedical sciences as well as the curses of depersonalized,
technology-driven medicine. Sulmasy’s meditations,
and the writings of authors gathered by MacKinlay,
push at the boundaries of current thinking about defining spirituality for research and practice. In addition,
they urge us to consider suffering and compassion in
a new light, with implications for practice as well as for
public policy.
What Are We Talking About?
Science requires researchers to define their constructs
and the ways they measure them to ensure precision
and replicability. However, for the scientific study of
religion and spirituality, agreement on definitions has
been elusive. Nearly every published empirical study
begins with reference to the challenge of defining these
terms, with researchers generally concluding that religion is more amenable to definition and measurement
than spirituality.
A major comprehensive review of research on
religion and health in the twentieth century opens
with a chapter on definitions (Koenig, McCullough, &
Larson, 2001) and presents the commonly accepted
view that spirituality is a more inclusive construct than
religion. Controversy persists about whether spirituality necessarily implies a transcendent object, with some
scholars asserting that defining spirituality as the search
for meaning and purpose allows for the possibility of
non-religious spirituality. Others, like Koenig (2007),
worry that such a broad definition of spirituality
conflates it with psychological well-being or mental
health; he insists that spirituality must involve connection to the sacred.
Various authors in Aging, Spirituality, and Palliative
Care reflect on the definitional controversy swirling
around the construct of spirituality, although not all of
them are specifically concerned about precise definitions
for research purposes. MacKinlay defines spirituality as
ultimate meaning mediated through relationships, the
environment, the arts, and religion, but she also states
that people can be spiritual without being religious. She
has employed this definition in action research on
spiritual needs assessment leading to guidelines for
spiritual care of older people in institutional settings.
Using longitudinal data from the Berkeley Guidance
Study and the Oakland Growth Study, Paul Wink’s research program (discussed in his chapter for MacKinlay)
has been consistent in defining religion and spirituality
as ‘‘two relatively independent dimensions’’ (p. 97). He
has borrowed from Robert Wuthnow (1998) the metaphors of ‘‘religious dwellers’’ and ‘‘spiritual seekers’’ to
differentiate them. The latter are persons who embrace
‘‘individual autonomy . . . over external authority’’ and
‘‘place a greater emphasis on self-growth’’ (p. 96). For
the research reported in this volume, Wink examined
death anxiety in late adulthood, finding that religiousness interacted with belief in an afterlife to predict older
people’s fears of death. Spirituality had no effect on
death anxiety. Wink interpreted this to be a function of
the more unconventional ways spiritual seekers approach their own personal growth.
Although much research in the late twentieth
century on spirituality, health, and aging was grounded
in the assumption that spirituality reflects an individual’s unique quest for meaning and purpose, there is an
emerging emphasis on spirituality as relational. Several
authors in Aging, Spirituality, and Palliative Care show
how this approach fits better with thinking about
health, healing, and palliative care. For example,
Rumbold argues that spirituality involves a ‘‘set of relationships that connect [the] individual to self, the social
world, and the environment’’ (p. 37). He provides a
brief but compelling social history of thinking about
spirituality and health in traditional, modern, and contemporary social organizations and states that we need
to move beyond thinking about spirituality as solely
involving individuals’ inner lives. Spirituality understood relationally requires examination of particular
settings and the values inherent in them. Do these
settings promote acknowledgement of human interdependence and support expressions of compassion for
the ill, or do they reinforce ‘‘competition, anxiety, selfinterest, and greed’’ (p. 40)? He argues that re-visioning
spirituality as relational creates a new conception of
spiritual care in health care settings with ethical and
social policy implications.
Sulmasy strongly endorses this view of spirituality.
For him, ‘‘spirituality is about transcendent relationship’’ that enables people to know themselves, their
neighbors, and the sacred more deeply (p. xii). He views
healing not as cure for disease but as the restoration of
relationships, even at the end of life. This perspective
puts him at odds with contemporary medical practice
which leaves him ‘‘nauseated by total quality management and evidence based medicine’’ (p. 17). He believes
that reintroduction of spiritual meaning to health care
is the only answer to the painful paradox experienced
by physicians today: they are capable of doing so much
for their patients, and yet they are highly stressed,
unappreciated, cynical, and highly dissatisfied with
their profession. As ‘‘depersonalized cogs in the wheel
of corporate medicine,’’ many have come to resent their
patients, for they have no sense of meaningful relationship or connectedness with them (p. 48).
Sulmasy declares that the physicians who invest
health care with spiritual meaning will come to see
‘‘medicine as one form of real love’’ (p. 74). Similarly,
several of the authors in Aging, Spirituality, and
Palliative Care emphasize the notion of relationality as
a core attribute of spirituality and move the discussion of
spirituality in a new direction by declaring that selfless
love, or agapé, lies at the heart of spiritual care and
compassion. This view of spirituality will undoubtedly
challenge researchers, especially those attempting to
uncover the mechanisms that account for connections
between religion, spirituality, and health. Indeed, one
possible outcome of viewing spirituality as essentially
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relational may be to reconnect it with religion, especially
since so many researchers have found better predictability of health outcomes from religious beliefs and
practices than from spiritual questing. The former nearly
always involves social connections.
More studies are needed to examine the nature of
those social connections and the expression of agapé
within them. Some qualitative researchers have begun
to do this work, including Ann Harrington, whose
chapter in Aging, Spirituality, and Palliative Care reported on a study of health care professionals working
with dying patients. A major finding concerned how
they conceptualized the interpersonal space surrounding patients and their families. Harrington’s interviews
showed that nurses, physicians, and hospice counselors
believed spiritual care occurred when they entered
that space in the spirit of agapé. Sensitive to the fact
that the term ‘‘agapé’’ can imply a specifically Christian
worldview, Harrington asserted that spiritual care is
not connected to any particular faith community, but
rather is found any time a care provider enters the
interpersonal space of another with an attitude of
altruistic love. Sulmasy calls this kind of connection a
‘‘profound moral event’’ (p. 32).
Suffering and Compassion
A recent paper makes the case that an important
missing element in research, practice, and policy about
caregiving is the recognition of the interpersonal connectedness that Sulmasy and several authors in Aging,
Spirituality and Palliative Care describe as occurring
when a person experiencing suffering is intentionally
approached with compassion. Though they do not call
this moment ‘‘spiritual,’’ Schulz et al. (2007) argue persuasively that suffering has an ‘‘existential or spiritual’’
component along with physical and emotional components, and that suffering can only be understood in
relational terms, involving both the one who suffers
and the caregiver (p. 5). They define compassion as ‘‘a
sense of shared suffering, combined with a desire to
alleviate or reduce such suffering’’ (p. 6). A key aspect
of compassion is the feeling of love and a sense of
interdependence. Their conceptual model shows the
relationship between suffering and compassion and it
provides a structure for research into various outcomes of this relationship for the one who suffers
and the one who gives care. In addition, they argue that
by understanding the intersection of suffering and
compassion, policy makers might promote better interventions to support those who suffer and those who
give care.
Though their work brings them into contact with
many forms of suffering and expressions of compassion, neither suffering nor compassion has been widely
addressed by gerontologists. In fact, at the end of a paper
describing qualitative research on themes of suffering
in late life, Black and Rubinstein (2004) concluded
that ‘‘this vast area of experience . . . remains largely
unexplored’’ (p. S22). They found that people generally
did not discuss their experiences of suffering, largely
because no one—including clergy—asked them to
The Gerontologist
describe the existential challenges they faced in resolving
what Sulmasy calls the ‘‘inherent tension between the
intrinsic dignity and the finitude of a person’’ (p. 74).
Provision of medical tests and treatments is insufficient
to resolve this tension. Suffering requires compassion. In
another paper reporting on interviews with older adults
suffering in a variety of ways, and the long-term-care
staff members caring for them, Black (2007) noted that
the most urgent issues facing these persons were
existential, not medical. Although the people interviewed in this study claimed not to be religious, they were
struggling with questions of meaning, questions that
they had little opportunity to discuss with anyone.
To approach a suffering person with openness to
hearing these questions, even though one may be
uncertain about the wisdom of providing answers,
requires a certain kind of courage and willingness to be
exposed to another’s existential and spiritual pain. As
Currow and Hegarty observe in Aging, Spirituality and
Palliative Care, creating connectedness with a person
who is suffering, while recognizing personal limits, is
‘‘the most difficult and challenging thing we are called
to do’’ (p. 134). Faced with an individual living acutely
with the tension between dignity and finitude, both
professional and family caregivers realize their own
vulnerability. This is especially challenging for medical
professionals. For example, Barbato, a palliative care
physician, wrote in Aging, Spirituality and Palliative
Care that he felt fairly confident about his ability to work
with dying persons. He believed he had ‘‘effectively
integrated the biomedical and holistic models’’ (p. 120)
into his clinical practice until he completed a course of
clinical pastoral education and discovered the risks and
challenges of being present to a patient, of entering the
interpersonal space of suffering without his ‘‘medical
bag of jargon, drugs, and tests’’ (p. 121).
Despite the many challenges of being present with
compassionate love to a person who is suffering, it is
nevertheless possible to experience joy in that encounter. One may discover what Robert Atchley describes in
his paper as the ‘‘robust resources for coping with
changing circumstances’’ expressed by many elders
who can surprise us with their ability to find humor
in difficult circumstances (p. 29). Corinne Trevitt and
MacKinlay relate many instances of humor that arose
in the spiritual reminiscence interviews they conducted
with people with dementia, and John Killick argues
strongly for the ways that people with dementia retain
the gift of celebrating life. However, of all the chapters
in Aging, Spirituality and Palliative Care, the one that
presents the clearest contrast to the stereotype of
seriousness and sadness in relationships with suffering
people is written by a clown.
Jenny Thompson-Richards masterfully relates her
experiences with two other clowns who form a team
working in a palliative care unit. They are supported
by the Humour Foundation which has trained over
40 ‘‘clown doctors’’ in Australia. I admit that I approached this chapter with some skepticism but
Thompson-Richards completely won me over with
her deep respect for the people whose lives she enters.
She describes the tender but funny choreography she
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and her clown colleagues enact as they approach dying
persons and ask for permission to be present to them.
As clowns, they lower their own status to elevate that
of the person who is bedridden, in pain, and often
fearful. She writes that ‘‘playfulness brings possibility
of expressing solidarity with humanity, of spaciousness
in our soul, wholeness of mind, body, spirit, and an
affirmation of life in all its fullness’’ (p. 148).
Thompson-Richards’ descriptions of her clowning
force us to examine critically many of the organizing
assumptions in the literature on religion, spirituality,
and health. It is possible that a researcher might want
to do a randomized clinical trial to test whether the
‘‘clown intervention’’ extends life for a day or a week.
But this hardly seems to be the point. While Schulz
et al. (2007) clearly have an important message about
the need for empirical studies of suffering and compassion, sometimes we need to let go of our drive to
place all human experience under the lens of science.
Compared to quantifiable interventions, clowning, and
many of the other approaches to suffering described in
Aging, Spirituality and Palliative Care and by Sulmasy,
are ‘‘soft’’, a description that has become pejorative
in our age. And yet, at the end of life, is it not softness
we desire—the softness of compassion from persons
willing to take the risk of entering into the relational
space with us?
Lessons Learned
Sulmasy wrote A Balm for Gilead specifically for
Catholic physicians and nurses. He explains what it
means to be a ‘‘Christian healer’’ within the Catholic
faith tradition. Though most people know a few things
about St. Francis, the stereotypical image of a garden
statue with birds on its head offers no insight into
Franciscan spirituality and its application to health
care. Sulmasy provides an accessible introduction to
the implications of Franciscan compassion not only
for the care of the sick but also for commitment to
social justice and changing a health care system that
dehumanizes people. In many ways, it is refreshing to
read a work about spirituality that is grounded in a
particular religion, for Sulmasy is able to draw on rich
resources of Biblical scholarship and theological interpretation. Moreover, unlike so much writing about
spirituality and health today, he sees no reason to try to
rationalize spirituality as a mechanism that will help
to explain variances in blood pressure readings, cancer
survival, or scores on a depression inventory. Instead,
he is more concerned about the role of spirituality in
the life of the healer, and strongly believes that medical
practice can only be improved if practitioners of the
healing arts take seriously the spiritual meaning of
what they do.
I am neither Catholic, nor a health care professional,
but still Sulmasy had much to teach me. For example,
his work challenges readers to think seriously about
‘‘workplace spirituality’’ and what it might mean in
various occupations. Although the phrase may evoke
disturbing images of workplace proselytizing, some
serious scholars are beginning to pay attention to
workplace policies that support employees’ attempts
to work out connections between what is good and
what is right within the framework of their religious
traditions and/or understanding of spirituality (e.g.,
Giacalone & Jurkiewicz, 2002). For example, Sulmasy
describes the need for physicians to establish a rhythm
of ‘‘reverent mindfulness’’ in which they turn their full
attention to the patients who enter their offices (p. 13).
Similarly, several authors in Aging, Spirituality and
Palliative Care talk about being fully present to people
who are suffering and dying. How might that discipline
of being present apply to the researcher in the
laboratory, the teacher in the classroom, the social
worker in the government office, the nurse in the clinic,
and the dietician in the kitchen? What difference might
this make in gerontological practice of all kinds?
Sulmasy’s harsh descriptions of physicians’ insecurity, resentment, and readiness to blame others (patients,
insurance companies, and corporations controlling
medical care) may also apply to university faculty
with stagnating salaries and increasing class sizes,
researchers facing cut-backs in grant funding, social
workers expected to do the work of three persons, and
activities directors overloaded with paperwork and
regulations. The contemporary workplace, whether in
the United States, Scotland, or Australia, often drains
so much energy from people that they might wonder
how they could possibly practice being mindfully present to others. Person-centered care, a growing movement worldwide, promises to relieve some of this
tension and improve life quality not only for older
people and those who are dying, but also for those who
care for them. The philosophy behind person-centered
care can also inform those teach others how to give
care, as well as the policy makers working to expand
and support this type of care. A Balm for Gilead and
Aging, Spirituality and Palliative Care reveal the interfaces between relational conceptualizations of spirituality and some of these broader issues of the workplace
and gerontological practice.
A final lesson learned from both of these books is
that all of us working under the big umbrella of
gerontology need to pay attention to social justice
issues and work for policy change that supports the
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personhood of all. This can be very frustrating and
discouraging. I vividly recall riding from the airport
to the GSA conference in Washington, DC, on a bus
full of rather depressed gerontologists after the most
recent United States Presidential election. Although
reading some of the chapters in Aging, Spirituality and
Palliative Care might produce envy for the kind of
programs being funded by the governments of Scotland
and Australia, envy is a rather ineffective emotion for
motivating the kind of hard work needed to create
social change. Instead, the message of both of these
books is that people who take spirituality seriously as
being about meaningful connectedness to the sacred,
and to other persons, need to be willing to risk working
for change—and healing—in systems and policies that
deny and degrade personhood.
Susan H. McFadden, PhD
Professor of Psychology
University of Wisconsin Oshkosh
Oshkosh, WI 54901
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The Gerontologist