The soul in medicine

The soul was a commonly invoked term during the 1950’s but has has largely declined in popular use in the USA.

According to an German-Jewish émigré general practitioner talked readily of medicine as a moral calling and about the souls of patients, family members, and physicians. He was not at all religious, so by “the soul” he appeared to mean the moral and spiritual core of the sick person, the family carer, and the professional healer. He had personally witnessed the corruption of “the souls” of the German people and of Nazi doctors. He recalled how the doctors themselves expressed interest in a medicine that claimed to treat the soul of the “Aryan folk”—a reminder that the term can be transmogrified into a dangerous hypocrisy. But in this gentle yet passionate family doctor’s ordinary speech, soul simply signified the way the sick experienced illness as a threat to their values, their deepest emotions, and their faith, and also the human way physicians treated their patients.

At Stanford University during the 1960s, professors in humanities courses used this idea of the soul. But in the social sciences and natural sciences, the word was never uttered. At Stanford Medical School, I came to understand that you didn’t mention the soul in a basic medical science course if you wanted to prevent derision, yet not so in the clinic. A few of the older clinicians still used it on occasion, especially to lament what they regarded as the effect of “big government” and “big business” in undermining the healing tasks of health professionals. By 1970 the word was not used by clinicians, even when religious patients and their families used it to frame the meaning of their illness and the source of hope.

William James, the physician, psychologist and educator, had banished the soul from his magisterial turn of the 20th-century Principles of Psychology. Later he resurrected the term and crafted an entire chapter on “The Sick Soul”. There he made the case for religion as an answer to the fundamental plea of people threatened by serious disease and other human crises to understand why bad things happen to them and to ask for help, divine and secular. It also helped them make sense of evil in the world.

Over the years Arther Kleinman the psychiatrists have come to use this antique term— which resonates with religious meaning—to represent that innermost existential centre to our being. ‘And here I would humbly suggest that the contemporary crisis of caring in health-care systems globally is implicating the soul, at least as I define it, through the frequent complaint that medicine and institutional health care are “soulless”. Meaning, I believe, that they fail to engage the most deeply human experiences that require care—not management.’

Kleinman recalls what happened in the hospital, ‘On one occasion, one of the medical students presented the example of speaking with a dying patient in the hospital, and being asked by her where the soul would go when she died. The student, I thought, handled the question brilliantly, by turning it back on the patient and inquiring sympathetically why this question was personally significant to her. She responded by revealing aspects of her family and personal life that were crucial to the care she should be receiving at the end of her life. But my co-teacher, who was a theologian, was profoundly upset and told the student: “But she asked you a technical question for which in the theology of her religion there is a technical answer.” From a doctrinal perspective she was right, but as a clinician I recognised his engagement with the patient was exemplary. So here is a sharp contrast between a way of engaging a patient via the idea of the soul that is medically useful and one that reveals the partisan nature of all religions that makes them so challenging for clinicians. Because once you invoke one religion you are pressed to relate it to one particular theology that excludes those who are not believers and claims an absolute truth for itself.’

The Diagnostic and Statistical Manual of Mental Disorders, fifth Edition (DSM-5), the “bible” of American psychiatric diagnoses, does not use the word soul as I have used it. But it does consider “soul loss” as a translation of culturally specific syndromes, especially “susto” among Latinos. Such moral and religious experiences are better left neither pathologised nor medicalised. Furthermore, a future edition of the DSM might well point to “soul loss” among patients confronting the threats of modern life who are traumatised by war, oppression, exploitation, and sexual assault and violence.

Kleinman goes on to explain further that, ‘In my own writing on care and caregiving, I find the expression “soulless” a resonant one to depict what is happening to caregiving in medicine in our times where the health system’s goals of efficiency and cost- effectiveness, new technological requirements that absorb the clinician’s alertness and attention, and the sheer pressure of insufficient time to listen and explain have a dire effect on providing the best of care. It is in the teeth of such dangerous charges that medical schools worldwide are experimenting with how to repurpose technology to support quality care and how to introduce the art of caring into the curriculum so as to prepare young doctors for crafting quality care in otherwise unpromising conditions and, in so doing, to inoculate themselves against burnout. As an old clinician I may sound like my clinical teachers from the 1960s who lamented changes in medicine and in their role as caregivers that were negating their moral and spiritual significance. Perhaps this is the perennial complaint, and to express it clearly we need soul to specify the human quality at the heart of care in order to animate the souls of patients, family members, and clinicians.’

Arthur Kleinman. www.thelancet.com Vol 394 August 24, 2019

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