Models of Caregiving
Bikkur Cholim: Sacred Visits as a Mitzvah of Relationship
Nancy Smith, LICSW, MAJS, BCC, Beth Israel Deaconess Medical Center
Derived by the rabbis from biblical and rabbinic texts, and considered a fulfillment of
“walking in God’s ways”, the value of the mitzvah (obligation) of bikkur cholim (visiting the sick) has not only endured for individuals, but has served as a foundation for the activities of the bikkur cholim societies of the Middle Ages to those of the more current Jewish healing movement. Through a review of biblical, rabbinic and later literature that provide the basis and philosophical underpinnings of this mitzvah, this paper will illuminate the power and value of this mitzvah particularly as it relates to the work of the Jewish hospital chaplain. Case vignettes drawn from this chaplain’s role in an academic medical setting, will illustrate how the tenets of this obligation can support and add a Jewish perspective to the training obtained through clinical pastoral education.
The life of the hospital chaplain is one of visiting. Whether by way of a request from a patient or family, at the recommendation of a staff member, or on the initiative of the chaplain, the visit forms the centerpiece of the hospital chaplain’s work. Ozarowski suggests that this work can be considered the “specialization and professionalization of the mitzvah [of bikkur cholim]”, not unlike other mitzvoth that involve trained professionals, such as brit milah (circumcision) and shechita (ritual slaughter). The chaplain is a spiritual healer in these encounters, addressing some of life’s most significant issues- meaning, forgiveness, trust, gratitude, identity and love. In the medical setting these issues may come to the fore in discussions of end of life, goals of care and patient/familial values. For the Jewish chaplain significant insight and wisdom may be drawn from the literature of bikkur cholim, a mitzvah described as not only visiting the sick but as also aiding in their healing.
This paper will present an overview of biblical, rabbinic and later literature and demonstrate how these sources became the rationale for, and were then behaviorally translated into, the specific components of a bikkur cholim visit. The applicability of these components to a spiritual care visit in the hospital setting will be addressed by examining a selection of case vignettes in which these components were applied. The case vignettes will also provide the opportunity for reflection on specific spiritual needs (belonging, identity, trust, and meaning) that were met by the chaplain when guided by these aspects of bikkur cholim.
Servants of All: David Hilfiker, Paul Farmer, and the Physician as Servant
Abraham Nussbaum, MD, Denver Health
In his classic text, Suffering Presence: Theological Reflections on Medicine, the Mentally Handicapped, and the Church, Stanley Hauerwas described the vocation of physicians as “to serve as a bridge between the world of the sick and the world of the healthy.” Over the past half-century, the texts of physician-writers have become a metaphorical bridge between physicians and patients, a cultural space in which they can explore the dynamics of their relationship. Physician-writers are widely read by laypeople eager to know what it is like to practice medicine and to understand how a physician views her patients. As a result, a reflective case report from The New England Journal of Medicine can be both the basis for a journal club at an academic medical center and, after it becomes a chapter in a bestselling book, the subject of a suburban book club. Physician-writers enjoy this dual audience because of their literary skill and the lay public’s fascination with medicine. While most popular physician-writers neglect the spiritual lives of their patients, two recent physician-writers, David Hilfiker and Paul Farmer, address the spiritual lives of patients and physicians in relationship to particular Christian theological traditions, liberal Protestantism and liberation theology, respectively. Despite their differences, both describe physicians primarily as the servants of the people they meet as patients. This self-understanding as servant is associated, in the writings of Hilfiker and Farmer, with a recognition of social injustice and a commitment to communal life. The writings of Hilfiker and Farmer will be engaged in the light of Hauerwas’ account that, for a physician to fulfill her vocation, she needs the church, or at least a community quite like the church.
“I Was Sick, and You Took Care of Me”: Caring for the Sick as a "Spiritual" Discipline and an Act of Economic and Ecological Justice
Joel Shuman, PhD, King’s College
Brian Volck, MD, Cincinnati Children's Hospital
Even to consider dividing the care of souls from the care of bodies – a notion fraught with Neo-Platonist, Cartesian, and Baconian assumptions – contradicts Christian theological tradition. The material of God’s good Creation isn’t easily segregated from matters of the spirit (Genesis 1:31, 2:7; 1 Corinthians 15:35-55). Concern for the total welfare of others is established in Torah (Leviticus 19:18), reaffirmed by the prophets (e.g. Amos 5:21-24; Isaiah 58:1-14), and driven home by the life and teachings of Jesus of Nazareth (e.g. Luke 10:25-37). The love of God and the love of neighbor are inseparable, and caring for the body of another is a “spiritual” act.
This is most clear in Jesus’s parable of the final judgment in Matthew (25:31-46), where bodily caring for the “least of these” – marginalized persons experiencing particular bodily needs – is an act of love directed toward Christ. Catholic tradition draws from this text the “corporal works of mercy,” which include care for the sick.
We argue that the spiritual practice of caring for the bodies of the sick includes, but also exceeds, the practice of medicine. As health care professionals well know, medicine, especially as it is practiced in the United States, has precious little to do with the health of particular human communities. That Americans are among the sickest people in the so-called “developed” world is often attributed to inadequate access to medical care. This may be correct, but only to a point: the causes of poor health among Americans are more complex than can be explained by limited access.
Why then are Americans so sick, even to the point that certain sectors of the population have recently been identified as having decreased healthy life expectancy? Recent surges in the incidence of so-called “lifestyle diseases,” including type-II diabetes and childhood asthma, disproportionally affect the marginalized, suggesting that where people live (or can afford to live), as well as what they eat (or can afford to eat) significantly affects their prospects for good health. “Lifestyle” is not something one chooses simpliciter, but something into which one is born and from which one cannot readily escape by force of will alone. These are not only public health issues, but matters of social, economic, and ecological justice as well, depending upon and flowing from how we treat our fellow creatures and all Creation. Caring for the sick, then, includes caring for the places they live and those from which they get their food.
Drawing from the disciplines of theology, literature, public health, nutrition, and epigenetics, we argue that: 1) modern biomedicine unnecessarily restricts and inadequately addresses matters of health, 2) a place and all its creatures properly constitutes the smallest unit of health, and 3) Christian accounts of Creation, Incarnation, and Ekklesia (church) demand active care for the health of persons and their places. We conclude by considering several communal practices that properly link health care to caring for God’s good Creation.
The Priestly Character of Medicine: John Zizioulas’s Eucharistic Vision in the Clinical Context, with Reference to Eric Cassell
Joshua Daniel, PhD, Saint Xavier University
In this presentation I explore the possibilities of Orthodox theologian John Zizioulas’s ‘Eucharistic vision of the world’—in particular, how he models humanity’s relation to nature—regarding the spiritual dimension of medicine. Zizioulas articulates his model of humanity’s relation to nature in a discussion of the ecological crisis, but I contend that it has application in the medical context, specifically the clinical encounter. Against the model of proprietor or lord and beyond the model of stewardship, Zizioulas advocates for the model of priest of creation. While the models of proprietor and steward both involve objectifying nature, the model of priest entails treating nature in an ontological-existential manner—or theologically stated, treating nature with love as God’s creation. Just as, in the Eucharistic liturgy, the priest is understood to elevate nature back into communion with God, and thereby save it from its finitude, so the priestly manner of relating to nature involves the exercise of our cultural creativity so that nature is referred back to God rather than human interests, and thereby developed for its own sake. These ideas can be applied to the medical context, insofar as the focus of medicine’s expertise—our biological organism—is one of the most natural or creaturely aspects of humanity. Whereas the model of proprietor aligns with the sort of medical paternalism brought to light in the middle of the twentieth century, and the model of steward is consonant with an impersonal, scientistic approach to medicine; the model of priest implies a medical personalism that refuses to isolate the biological organism from the more existential and spiritual aspects of humans.
With comparative reference to Eric Cassell, I intend to advance three claims regarding Zizioulas’s modeling of humanity in the medical context. First, the priestly character of medicine is cultural in the sense that it involves attention to the meanings attributed to sickness and healing. Especially in cases of long-term sickness or fatal disease, healing involves transforming the meanings that patients attribute to their ailments. Second, given the cultural aspect of the priestly character of medicine, healing requires biographical-ethnographical work, on the part of both physician and patient. While the models of proprietor and steward would suggest that the physician is the agent of healing, the model of priest demands that healing is accomplished between physician and patient. Not only must physicians learn enough about their patients to contextualize their diseases within the varying idiosyncrasies of their personal lives so as to discern how they attribute meanings; physicians must do this work upon themselves, so that their contribution to healing is personal as well. Third, the medical context requires resisting a particular aspect of Zizioulas’s model of priest of creation, namely, its understanding of referring nature to God as the overcoming of nature’s finitude so that it becomes permanent. Again in cases of long-term sickness or fatal disease, healing involves our recognition of and reconciliation with human finitude. Such recognition and reconciliation comprise the truly priestly character of medicine.
Nancy Smith, LICSW, MAJS, BCC, Beth Israel Deaconess Medical Center
Derived by the rabbis from biblical and rabbinic texts, and considered a fulfillment of
“walking in God’s ways”, the value of the mitzvah (obligation) of bikkur cholim (visiting the sick) has not only endured for individuals, but has served as a foundation for the activities of the bikkur cholim societies of the Middle Ages to those of the more current Jewish healing movement. Through a review of biblical, rabbinic and later literature that provide the basis and philosophical underpinnings of this mitzvah, this paper will illuminate the power and value of this mitzvah particularly as it relates to the work of the Jewish hospital chaplain. Case vignettes drawn from this chaplain’s role in an academic medical setting, will illustrate how the tenets of this obligation can support and add a Jewish perspective to the training obtained through clinical pastoral education.
The life of the hospital chaplain is one of visiting. Whether by way of a request from a patient or family, at the recommendation of a staff member, or on the initiative of the chaplain, the visit forms the centerpiece of the hospital chaplain’s work. Ozarowski suggests that this work can be considered the “specialization and professionalization of the mitzvah [of bikkur cholim]”, not unlike other mitzvoth that involve trained professionals, such as brit milah (circumcision) and shechita (ritual slaughter). The chaplain is a spiritual healer in these encounters, addressing some of life’s most significant issues- meaning, forgiveness, trust, gratitude, identity and love. In the medical setting these issues may come to the fore in discussions of end of life, goals of care and patient/familial values. For the Jewish chaplain significant insight and wisdom may be drawn from the literature of bikkur cholim, a mitzvah described as not only visiting the sick but as also aiding in their healing.
This paper will present an overview of biblical, rabbinic and later literature and demonstrate how these sources became the rationale for, and were then behaviorally translated into, the specific components of a bikkur cholim visit. The applicability of these components to a spiritual care visit in the hospital setting will be addressed by examining a selection of case vignettes in which these components were applied. The case vignettes will also provide the opportunity for reflection on specific spiritual needs (belonging, identity, trust, and meaning) that were met by the chaplain when guided by these aspects of bikkur cholim.
Servants of All: David Hilfiker, Paul Farmer, and the Physician as Servant
Abraham Nussbaum, MD, Denver Health
In his classic text, Suffering Presence: Theological Reflections on Medicine, the Mentally Handicapped, and the Church, Stanley Hauerwas described the vocation of physicians as “to serve as a bridge between the world of the sick and the world of the healthy.” Over the past half-century, the texts of physician-writers have become a metaphorical bridge between physicians and patients, a cultural space in which they can explore the dynamics of their relationship. Physician-writers are widely read by laypeople eager to know what it is like to practice medicine and to understand how a physician views her patients. As a result, a reflective case report from The New England Journal of Medicine can be both the basis for a journal club at an academic medical center and, after it becomes a chapter in a bestselling book, the subject of a suburban book club. Physician-writers enjoy this dual audience because of their literary skill and the lay public’s fascination with medicine. While most popular physician-writers neglect the spiritual lives of their patients, two recent physician-writers, David Hilfiker and Paul Farmer, address the spiritual lives of patients and physicians in relationship to particular Christian theological traditions, liberal Protestantism and liberation theology, respectively. Despite their differences, both describe physicians primarily as the servants of the people they meet as patients. This self-understanding as servant is associated, in the writings of Hilfiker and Farmer, with a recognition of social injustice and a commitment to communal life. The writings of Hilfiker and Farmer will be engaged in the light of Hauerwas’ account that, for a physician to fulfill her vocation, she needs the church, or at least a community quite like the church.
“I Was Sick, and You Took Care of Me”: Caring for the Sick as a "Spiritual" Discipline and an Act of Economic and Ecological Justice
Joel Shuman, PhD, King’s College
Brian Volck, MD, Cincinnati Children's Hospital
Even to consider dividing the care of souls from the care of bodies – a notion fraught with Neo-Platonist, Cartesian, and Baconian assumptions – contradicts Christian theological tradition. The material of God’s good Creation isn’t easily segregated from matters of the spirit (Genesis 1:31, 2:7; 1 Corinthians 15:35-55). Concern for the total welfare of others is established in Torah (Leviticus 19:18), reaffirmed by the prophets (e.g. Amos 5:21-24; Isaiah 58:1-14), and driven home by the life and teachings of Jesus of Nazareth (e.g. Luke 10:25-37). The love of God and the love of neighbor are inseparable, and caring for the body of another is a “spiritual” act.
This is most clear in Jesus’s parable of the final judgment in Matthew (25:31-46), where bodily caring for the “least of these” – marginalized persons experiencing particular bodily needs – is an act of love directed toward Christ. Catholic tradition draws from this text the “corporal works of mercy,” which include care for the sick.
We argue that the spiritual practice of caring for the bodies of the sick includes, but also exceeds, the practice of medicine. As health care professionals well know, medicine, especially as it is practiced in the United States, has precious little to do with the health of particular human communities. That Americans are among the sickest people in the so-called “developed” world is often attributed to inadequate access to medical care. This may be correct, but only to a point: the causes of poor health among Americans are more complex than can be explained by limited access.
Why then are Americans so sick, even to the point that certain sectors of the population have recently been identified as having decreased healthy life expectancy? Recent surges in the incidence of so-called “lifestyle diseases,” including type-II diabetes and childhood asthma, disproportionally affect the marginalized, suggesting that where people live (or can afford to live), as well as what they eat (or can afford to eat) significantly affects their prospects for good health. “Lifestyle” is not something one chooses simpliciter, but something into which one is born and from which one cannot readily escape by force of will alone. These are not only public health issues, but matters of social, economic, and ecological justice as well, depending upon and flowing from how we treat our fellow creatures and all Creation. Caring for the sick, then, includes caring for the places they live and those from which they get their food.
Drawing from the disciplines of theology, literature, public health, nutrition, and epigenetics, we argue that: 1) modern biomedicine unnecessarily restricts and inadequately addresses matters of health, 2) a place and all its creatures properly constitutes the smallest unit of health, and 3) Christian accounts of Creation, Incarnation, and Ekklesia (church) demand active care for the health of persons and their places. We conclude by considering several communal practices that properly link health care to caring for God’s good Creation.
The Priestly Character of Medicine: John Zizioulas’s Eucharistic Vision in the Clinical Context, with Reference to Eric Cassell
Joshua Daniel, PhD, Saint Xavier University
In this presentation I explore the possibilities of Orthodox theologian John Zizioulas’s ‘Eucharistic vision of the world’—in particular, how he models humanity’s relation to nature—regarding the spiritual dimension of medicine. Zizioulas articulates his model of humanity’s relation to nature in a discussion of the ecological crisis, but I contend that it has application in the medical context, specifically the clinical encounter. Against the model of proprietor or lord and beyond the model of stewardship, Zizioulas advocates for the model of priest of creation. While the models of proprietor and steward both involve objectifying nature, the model of priest entails treating nature in an ontological-existential manner—or theologically stated, treating nature with love as God’s creation. Just as, in the Eucharistic liturgy, the priest is understood to elevate nature back into communion with God, and thereby save it from its finitude, so the priestly manner of relating to nature involves the exercise of our cultural creativity so that nature is referred back to God rather than human interests, and thereby developed for its own sake. These ideas can be applied to the medical context, insofar as the focus of medicine’s expertise—our biological organism—is one of the most natural or creaturely aspects of humanity. Whereas the model of proprietor aligns with the sort of medical paternalism brought to light in the middle of the twentieth century, and the model of steward is consonant with an impersonal, scientistic approach to medicine; the model of priest implies a medical personalism that refuses to isolate the biological organism from the more existential and spiritual aspects of humans.
With comparative reference to Eric Cassell, I intend to advance three claims regarding Zizioulas’s modeling of humanity in the medical context. First, the priestly character of medicine is cultural in the sense that it involves attention to the meanings attributed to sickness and healing. Especially in cases of long-term sickness or fatal disease, healing involves transforming the meanings that patients attribute to their ailments. Second, given the cultural aspect of the priestly character of medicine, healing requires biographical-ethnographical work, on the part of both physician and patient. While the models of proprietor and steward would suggest that the physician is the agent of healing, the model of priest demands that healing is accomplished between physician and patient. Not only must physicians learn enough about their patients to contextualize their diseases within the varying idiosyncrasies of their personal lives so as to discern how they attribute meanings; physicians must do this work upon themselves, so that their contribution to healing is personal as well. Third, the medical context requires resisting a particular aspect of Zizioulas’s model of priest of creation, namely, its understanding of referring nature to God as the overcoming of nature’s finitude so that it becomes permanent. Again in cases of long-term sickness or fatal disease, healing involves our recognition of and reconciliation with human finitude. Such recognition and reconciliation comprise the truly priestly character of medicine.