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-Spiritual Dimension of Health Care-

The author probes into the origin of medicine and illuminates how religion took an essential part in the birth of ancient medicine in both East and West.
In the modern age, medicine as science continues to attain a high level of progress. Yet simultaneously, medicine interacts with the spiritual and religious realm of the human mind. The hospice movement, started by Cecily Saunders in 1967, strongly encouraged this tendency, and now spiritual care is acquiring much importance in global medicine.

All of us fall ill at some point in life; aging brings decline, and eventual death ends it all. This is the ultimate inevitability of life. According to Buddha, there are four types of suffering in life: living, old age, illness and death. Furthermore, Buddha realized that the four sufferings are unavoidable if one were to keep on living. With this revelation, Buddha was awakened and left the secular world to pursue enlightenment. It then enabled him to transcend the four sufferings, and he attained the state of nirvana, complete peace.
The British master playwright Shakespeare writes of the death in Julius Caesar, Act 2, Scene 2 as:
"Seeing that death, a necessary end,
Will come when it will come."
A necessary end, death is the inevitable destiny of man. 

East or West, one perceives oneself, a human being, to be a fragile creature. And this recognition makes him desire some type of salvation. The means to attain such salvation since antiquity were often identified as medicine on one hand, and religion on other.
An ailing person primarily forms a close relationship with physicians and nurses who provide scientific remedial skills. This has been the case regardless of age or race, or nationality. However, while receiving such medical care, the ailing person yearns for teachers, friends, or religion as providers of spiritual support.
In the ancient era, the remedial skills of medicine were primitive and scarce. There were very few physicians close-by who would come and heal them completely. Consequently, there arose a spontaneous dependence upon the power of nature, which appeared then to rule the entire universe. The dependency was subsequently transformed into animistic beliefs involving mountains, seas, the sun and the moon, worship of which provided spiritual support for those stricken with illness.

In ancient Japan, there seems to have been no social group similar to modern-day medical professionals. However, even at that time, a learned person with many years of experience, called "Kusu (medicine) shi(professional person)," provided healing to those who were ill in both body and mind. In today's sense, therefore, "Kusu-shi" might have been a "care-giver" who had experience and knowledge in caring for the sick.
On the other hand, an ailing person and his family visited Buddhist temples and Shinto shrines of ancient Japan often to pray for divine benevolence and healing. Eventually a series of rites evolved, in which offerings of crops and animal sacrifices were presented to the altar. The rites and customs then were disseminated to other communities, and succession followed.
Over the course of time people interacted with different communities, tribes and nations more frequently. Through all this, a variety of alternative healing practices, as well as scientifically sound treatments of illnesses, came to be known widely. The exchange of knowledge was a two-way transmission and communication between East and West. An insight had existed since antiquity in every part of the world: a human being was created by a supreme transcendental power, which possessed astonishing depth of wisdom. For example, genes, an amazing tool of heredity and succession of life, came to be known only in the first half of the 20th century. Yet without such knowledge, the mysterious mechanism of healing power, which was naturally endowed in a human body, was known to charismatic religious leaders and brilliant physicians. A pertinent example of this would be the immune system. The leaders and physicians made use of the natural healing mechanism, which materialized into healing techniques that must have appeared like miracles at the time.
We all come to realize that cosmic phenomena are the expression of the principles of the universe, and that they are often beyond human intellectual reasoning. Examples would be: the celestial movements of the heavenly bodies in the sky; the passage of the four seasons on earth; growth and passing of all living things around us. The ultimate such example is the fact that human life is sustained within, and by the force of, the inexplicable principles of the universe. Such facts, presented to the human mind, must have been stunning. At the same time, these facts must have illuminated those minds profoundly. As the result, one sensed in awe the existence of great powers that are invisibly present. It is at such moments that religious feelings arise in our minds.
The history of mankind extends over a long period of time. Within this history, Buddha, Mohammed, and Jesus Christ appeared. People who heard their words and witnessed their work experienced feelings of religiosity, and were filled with new thoughts on living and dying. The new perspective was passed on to succeeding generations, and missionary works were organized in various religious denominations in order to propagate it.
However, at the dawn of the modern age, natural sciences progressed rapidly. Simultaneously, great geographical discoveries, such as the discovery of the American Continent by Columbus, stimulated international communications among the countries of the world. The wave of international exchanges helped to disseminate scientific knowledge. The learning thrived in various countries in the world.
Let me remind you that in ancient Greece and Rome, medicine ranked lower than theology. Yet medicine was the highest-ranked discipline in natural sciences, and it surpassed astronomy. This had changed by the dawn of the 18th century. Physics, biology and chemistry, major disciplines of the natural sciences, advanced in leap and bounds. These disciplines influenced and strengthened 19th century medicine, and medicine took a sudden growth as an applied natural science. The progress then brought about an excessive emphasis upon scientific knowledge in medicine. Due to this emphasis on the scientific aspects of medicine, human spirituality became increasingly ignored and neglected in the overall practice of medicine.

In the latter half of the 20th century, rapid progress in natural sciences contributed to even greater sophistication of medicine. Meanwhile the art of healing the sick, cultivated over time both in East and West, gradually declined. It came to carry much less weight in medical practice.
Professor William Osler was a founding member of Johns Hopkins University Medical School, which was established at the end of the 19th century. Professor Osler left us with the following memorable words: "Medicine is an art based on science." Since his lifetime, this and many other words of his became a source of reflection for all medical care-givers with professional conscience. His memory and the impact of his words persist today.
Now that we face the end of the beginning of the 21st century, medicine around the world is turning its attention to the interaction of body and mind. Mind is an entity contained within the body. Physicians started recognizing this and they in turn thought about the essence of human life, and the necessity to restore it. This concept had been neglected in modern medicine while it was in rapid progress along with other disciplines of natural science. The renewed reflection on this point, on the essence of human life and necessity to restore it, led to the new term "quality of life." And as we all know, topics relating to "quality of life" are now receiving worldwide attention.
Harvard University Medical School is one of the major private medical schools of the United States. It is interesting that their curriculum became increasingly interdisciplinary in the latter half of the 20th century. The curriculum began incorporating faculty and specialists in theology, psychology, behavioral sciences and medical history, making these studies an essential part of medical education.
In recent years, discussion arose within the WHO suggesting that the term spiritual be added into the phrase "complete physical, mental and social well-being". Here, the word "spiritual" relates directly to the essence and value of human life, a reason for living, or personal fulfillment.
All refer to the spiritual aspect of human existence. This discussion arose because the health professionals came to realize that, without spirituality, complete health is not possible.
As we think on this point, a question should be asked: How many people in Japan and the West think this way? And how many religious believers pay serious attention to this topic in their religious pursuits?

Let us ask first: how many Japanese people believe in religion? To what religious denominations do they belong? It is extremely difficult to obtain accurate figures regarding this statistic. The available data as of December 31, 1996 report that 44.1 % of the entire Japanese populations believe in some sect of Buddhism. The report goes on to list that 49% believe in Shintoism, Christians (both Catholics and Protestants) comprise 1.5 % of the population, and 5.2% believe in some religions outside the previous three categories.
However, the percentage may not reflect the actual number of firm believers. This is because these figures are frequently derived from the answers to a questionnaire: "What style of funeral rites did you select? "Those who chose to perform Buddhist funerals were counted as Buddhists, and the same went for the Shintoists. To ascertain accurately the number of serious religious believers in Japan is therefore quite difficult. By the same token, the statistics provided by the individual religious organizations are equally unreliable.
What might be useful would be the data provided by a monograph titled "Nihonjin no Shinkoushin [Religious Faith of the Japanese People]" (Kodansha Shinsho, 1983). It compares the Japanese data with the relevant data of the West.
Let me remind you that in Japan, Christianity is more readily adopted by the intellectuals. Yet, in spite of its 126-year-history during which painful efforts and sacrifices were made on the part of the missionaries, the number of church-going Christians, Protestants and Catholics together, is less than 1%. This is still much lower than might be expected.
According to the author of the above monograph Tadamasa Isobe, the low rate of conversion to Christianity in Japan is attributed to the spiritual structure of Japanese society. Here,Christianity cannot be accepted as religious consciousness in the minds of the Japanese people. Isobe points out that no matter how advanced and sophisticated Japanese culture becomes, the Japanese people cannot liberate themselves from reversion to their primeval origin (Isobe avoids the use of the term "returning to the ancestors.") In other words, the Japanese will never free themselves from ancient animism, the view that Buddha's nature is inherent in all things.

Since I intend to discuss health care and religion, I will remove from the realm of my discussion the new religions that promise quick earthly benefits, or preach radical and fantastic doctrines. Instead, let me consider the established orthodox religions that have stood the test of time:Buddhism, Christianity, and Islam.
Do humans aspire to eternity? On this matter I am in complete agreement with Professor Seiichi Hatano (1877-1950) of the Department of the Philosophy of Religion, Faculty of Literature at Kyoto University. He states that "human beings yearn for eternal life, and that is the essence of religiosity in human nature." In Japan, the numbers of physicians who believe in "truth-telling" have increased rapidly in recent years. More physicians notify their terminally ill patients of the true diagnoses and prognoses. In the past, such information was never released to the patients themselves; only close family members were informed. Along with this "truth-telling," death education is in progress in Japan. One is now encouraged to prepare for one's own death beforehand. Youngsters are also advised to think about death from an early age.
In view of this tendency, I anticipate that, in the future, the link between health care and religion will grow stronger.
Christianity preaches that the human soul is saved through Jesus Christ. The teachings of the Pure Land Sect of Japanese Buddhism are contrary to this. It firmly believes in the Pure Land, a dimension of eternity. The doctrine of the Pure Land Sect is intertwined with the native ancestor worship, and preaches aspiration for eternity in the Pure Land. It also teaches that the transmigration and rebirth of the soul takes place. I perceive that such faith, that eternity exists in the Pure Land and the transmigration and rebirth of the soul takes place, will save the Japanese people in the future. Belief in such faith will alleviate one's anxiety about old age; it will lessen suffering caused from illness; it will assuage the fear of death.
In 1967, Dr. Cicely Saunders founded the first modern hospice in Britain. Since then, the movement to establish modern hospices has spread in Japan. I myself have built one, and saw with my own eyes how extensive palliative care eased the pain of terminally ill patients. Frontline medical technology, such as optimum management of morphine administration, has been generously applied. At the same time spiritual care was taken into an account and was exercised thoroughly. Then I saw the patients' fear of death lessen. The patients became calm, and serene. Eventually they entered into a mental state where they wished for spiritual healing, and salvation.
I also saw the patients retain serenity of mind even when facing imminent death. And at the time of passing, they left words of gratitude. They were grateful for their own lives; they said words of thanks to their children, close friends and to the younger generation. Seeing all that, I came to believe that hospice care provides happiness to the dying in the true sense of the word.

Let me illustrate my view of health care by using an inverted triangle. To the upper left of this inverted triangle rests "medical knowledge." To the upper right, "advanced technology." These two combined can offer a highly sophisticated medical treatment based on scientific knowledge and technology.
At the bottom point of this inverted triangle, where the above two converge, rest the caregivers. I hope health-care professionals will sensitively channel this high-level scientific health care to the gravely ill or dying patient at the bottom of the pyramid, and will provide compassionate as well as medical care. I am talking about holistic care. To make this work effectively requires not only skill in relieving physical suffering but also a sensitive approach to emotional and spiritual concerns. In short, true health-care professionals need to be equipped with the power to heal minds as well as bodies.
If they are to understand the sick and dying holistically, healers will be expected to have the kinds of skills that enable them to reach the mind and spirit within the earthen vessel that is the body. What is wanted is good encounters between religiously inclined patients and health-care professionals. Only when that happens, I believe, will the spirit of Osler, who defined medicine as an art based on science, truly breathe life into modern medicine. END 


This lecture was given at the 9th Asian Chapter of the International
College of Psychosomatic Medicine, (Sept. 29-30, 2000, in Tokyo)

Shigeaki Hinohara, M.D.
Honorary President,
St. Luke's International Hospital,
Tokyo, Japan.