Spiritual Thinking and Surgery

A doctor’s conduct in his clinical activity, his relationship with the patient, not only serve as a role model for new generations but are all elements that make up his way of being a doctor and they are inevitably influenced by his human nature. In this walk of life, whether a person has or doesn’t have a spiritual attitude makes a very significant difference.

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23 November 2021
© Springer Nature Switzerland AG 2021 - C. Doria, J. N. Rogart (eds.), Hepato-Pancreato-Biliary Malignancies

Spiritual Thinking and Surgery

Prof. Ignazio Marino - Thomas Jefferson University, Philadelphia, PA, USA - e-mail: ignazio.marino@jefferson.edu

The ways in which patients ask for help from doctors have not changed over the centuries: weakness, fear of pain, and the anguish of losing physical strength remain the same. What has changed radically is the attitude and the role of doctors who once represented an important point of reference for society. Today they appear disoriented and confused in the face of the profound changes to the health system and its organization. Without denying all the progress achieved through the positive aspects of technology and the hyper-specialization of doctors, one should reflect on the gradual loss of the sense of mission that should be a fundamental characteristic of the medical profession.

It is essential to consider the human component which affects the way doctors use their knowledge and training – their way of thinking about life, their spirituality, their faith if they have one – in their efforts to help the patient. Also, doctors must not forget that they have the huge responsibility to train new generations since they necessarily serve as models of inspiration for students and younger practitioners.

This chapter examines the reasons and the engine that has fueled a transformation of the medical profession. From being the sole repository of the knowledge necessary for one’s health, the doctor has become the employee of a highly technological system based on business practices and is asked to follow preestablished protocols and apply procedures that allow a complicated system to function but are often far from what medicine should really be about. The author also considers the role that spirituality and faith might have in the practice of medicine and in the healing process.

 

Shamans, Scientists, and Hospitals

Entering a sacred place is always a moving experience. It may distress us or induce reflection, but it is never neutral. The objects, the light, the smells, the muted sounds, the songs of the faithful – everything suggests the presence of a divinity (by whatever name you may want to call it). In the church of syncretic rites in San Juan Chamula, during a trip to Chiapas, Mexico, I was fortunate to be present at a healing ceremony conducted by a shaman.

While the light from a cool spring morning entered the building’s high windows, the central nave remained in shadows, and there, just a few steps away from what must have been the altar, a tall man with long white hair and arms covered by multicolored ribbons looked intently at the face of a peasant, feeling his pulse to make out its beat and understand what was broken in the balance of nature. According to the tradition of that small community, in fact, a man’s illness is nothing more than the expression of a problem that has befallen an animal in the jungle. That peasant had a sort of twin in the forest, born at the same moment as he, and so creating an indissoluble bond between them.

The shaman, accompanied by several string instruments playing a sweet and repetitive melody, made his diagnosis. Seated on a carpet of aromatic pine needles, drunk with the perfume of incense burnt in huge black chalices among statues and images of Christian saints, and almost hypnotized by the flames of hundreds of candles set out on the floor, I watched the healing rite carried out through formulae that I could not understand: the sacrifice of a chicken, the offer of an egg to the divinity. In a totally natural way, the practice of medicine and religion were intertwined, imbuing the first with a sacred quality that we too have known in a not too-distant past. Before diagnostic tools like the CAT scan or the MRI became part of the normal practice in evaluating pathology, often the only way of making certain that a patient had cancer was to “open him/her up,” that is, to explore the abdomen surgically. Until the 1970s, the figure of the surgeon – always a male – truly resembled that of a priest: he presented himself in the operating room with a long gown down to his calves, hardly ever spoke, and the rare phrases that he pronounced were understandable only by the few faithful assistants who helped him during his surgeries.

Most of the time when he opened a patient’s abdomen to ascertain the presence of a tumor, the only thing he did was to rinse the abdominal cavity with a physiological solution before closing it. In the language of the specialists this procedure was called, without an attempt at irony, “a breath of air.” Miraculously, the patients sometimes felt better after their tumors had taken a breath of air, but quite honestly – no sarcasm intended – the scientific worth of the procedure was not much different than the sacrifice of a chicken.

The important thing was that the patient believed blindly in what the surgeon had decided to do. He did not dare doubt the method and, on the contrary, accepted everything silently, feeling a great sense of gratitude.

Even today, some doctors who specialize in therapies that require highly sophisticated technologies are in a sense surrounded by an aura of sacredness, defined by the exalted term “luminaries.” Often proud and detached, these scientists command a technology that is impenetrable to most people and use terms so complex that they sound like magic formulae to the uninitiated. Even their gestures within the sterile space of an operating room are not so different from those performed by a shaman, and certainly they are just as incomprehensible from the patient’s point of view. When a person goes through radiation therapy, for example, he or she is brought inside a room resembling a white bunker sealed off by a heavy door that blocks the radiation. The contact with the rest of the world occurs only through a thick glass: on the other side, expert hands guide invisible rays. There is no sound, there is nothing to see or hear; a sense of mystery prevails over any other sensation. Nevertheless, there the patient is hit, without having an immediate physical awareness, by extremely potent radiation able to precisely target the point of the body where the tumor has developed, even if it is only a few centimeters in size.

Let us think about another specialty, interventional cardiology. Until a few decades ago, someone with a heart problem either died without any knowledge of the illness or went through a complicated surgical procedure with his/her chest laid open for the replacement of part of the obstructed artery: a procedure with many risks and a long, arduous period of postoperative recovery. Today, for the same sort of problem, the cardiologist merely introduces a thin catheter into the patient’s groin and pushes it along the aorta to the coronary arteries, where he/she inserts a plastic stent that holds open the part of the artery that is narrowing because of cholesterol. In this way, the normal flow of blood to the heart is re-established, and everything is done under fluoroscopic guidance, that is, with an X-ray machine that allows us to follow on a video monitor each small movement of the catheter inside the body. The operation takes at most a couple of hours and is done with a local anesthetic. Patients, along with the doctor, can watch their beating heart on the screen and see the catheter entering the blocked artery, moving rapidly like a cunning snake. In reality, for those patients, the procedure is magical: even if it happens before their eyes, they cannot fully understand what is happening inside their body, so the gestures of the cardiologist, as a miracle worker, are not so unlike those of the shaman in the church of syncretic rites.

The association between spirituality, religion, and medicine in the world and in Western culture can be grasped simply by looking at how patients turn to the doctor with great hope to find relief of their own bodily suffering, not unlike how we ask aid and comfort from a divinity when faced with situations of particular difficulty. The ways in which a sick person asks for help from a doctor have not changed with the passing of years, or even centuries – weakness in the face of sickness has always been the same, accompanied by fear of pain, and the anguish of losing one’s physical strength.

What has changed radically is the attitude and the role of practitioners of medicine, not the “luminaries,” but the thousands of doctors who once upon a time represented an important point of reference for society. Today they seem puzzled, disoriented, and confused in the face of the profound changes to the health system and its organization in the last fifty years.

This chapter examines in depth the reasons for that change and the engine that has fueled this transformation of the medical profession. From being the sole repository of the knowledge necessary for one’s health, the doctor has become the employee of a health care system based on business practices and is asked to follow preestablished protocols and apply procedures that allow a complicated system to function but are often far from what medicine should really be about.

What do you do? What is your profession? Americans often ask. In most cases, a doctor’s answer is very precise: I am an anesthesiologist, a nephrologist, a gynecologist, etc. It is rare to get a generic answer like: I am a doctor. This difference may seem like a linguistic subtlety but, in reality, it implies a clear definition of the role of every doctor within a vast and complex health system where everyone has become a specialist: of a single organ, of a disease, of a function of the human body, or master of a single technique. But the vast technology associated with the organizational needs of the hospital, with its economy, with the need to make plans far in advance to assure the correct functioning of the system – all these elements contribute to the formation of hyper-specialized doctors. The tendency to focus on the specific clouds a vision of the whole to the point that it is not rare these days to run into professionals, expert in extremely complex surgical procedures, like a liver transplantation or a liver resection, who have difficulty with diagnosing something as simple as an inguinal hernia. This process is by now prevalent in American society and culture and is expanding rapidly into a more conservative Europe. Doctors study diseases, evaluate tests, prescribe treatments, operate, and in many cases contribute to the patient’s cure, yet still do not manage to get a complete picture of the person’s problems. Not to mention the now widespread inability to recognize a patient’s global malaise which always has a physical and a psychological component, both present in the moment when one asks a doctor for help. This approach is exactly the opposite of the traditional medicine used widely in all the Asian countries. In Tibetan, Chinese or Ayurvedic medicine, illnesses are considered problems of the whole person, a result of the loss of balance with nature, the lack of harmony with oneself and with the universe, and the loss of symmetry between mind and body.

The Taoist text Lieh Tzu describes Pien Ch’iao, Chinese physician and surgeon (450 BC) replacing diseased hearts with healthy ones. The two patients as Gong Hu 公扈and Qi Ying 齊嬰 had opposite imbalances of qi 氣“breath; lifeforce” and zhi 志“will; intention”. Apparently, they recovered but besides the myth the story tells how surgery and medicine have always been connected with a holistic approach, focusing on a person’s wellness, far beyond just his physical illness.

Without denying all the progress achieved through the positive aspects of technology and the hyper-specialization of doctors, one should reflect on the gradual loss of the sense of mission that should be a fundamental characteristic of the medical profession: to rediscover the passion for a job that is at the same time the choice of a life which doctors can give themselves to, whole heartedly. According to this view, one must also consider the human component which affects the way doctors use their knowledge and training – their way of thinking about life, their spirituality, their faith if they have one – in their efforts to help the patient. And the relationship a doctor establishes with the patient is inevitably bound to reflect all these elements.

Furthermore, doctors must not forget that they have a great responsibility in training new generations, since they necessarily serve as models of inspiration for them. For this reason too, it is not right to sit back and let the example of confused or greedy and disillusioned doctors prevail.

The method of training doctors cannot be based only on a transfer of information. To train someone means above all to assign worth to the students standing before you, to their hopes and goals. This implies making an effort to know them – investing time and energy in motivating and following them – giving them responsibility without abandoning them and being engaged in developing their spirit of observation and selfconfidence. It means recognizing that this role is a priority, a responsibility. In the field of medicine, it means demonstrating with words and actions what it means to be a doctor. The true challenge of this profession is not in learning a theory or executing a technique, but in knowing how to harmonize technique and conduct, cultivating and developing a particular sensibility towards other people.

When I was in medical school, I spent most of my time on books, studying, memorizing the necessary information to pass the exams. But for me and my colleagues in the class, the teachers who inspired us most were not the most illustrious professors – as famous as they were absent from the daily activities of the ward. Rather, we preferred to follow the least-known doctors who spent their days in the hospital, some in the laboratory, some with patients, never complaining and sincerely attached to their profession. It was above all those invisible doctors with no recognition for their dedication who taught us a great deal, allowing us to shadow and observe them, and who were always willing to spend a moment with us students to explain why certain things happened and the reasoning behind clinical decisions.

I remember an assistant in microbiology who “read the plates” every morning, that is, examining the blood or urine cultures to identify the particular bacteria present, and their response to antibiotics. It was not a proper university course and there were no exams to take at the end of the year, but there were many of us who participated in that reading. Many things can be understood about the prescription of therapies thanks to the observation of the behavior of bacteria; but above all, we were drawn to that doctor’s enthusiasm and to his capacity to transmit important information which we would never have found in the textbooks.

Some rethinking in the training methods and in the concept of professionalism is clearly indispensable to give hope to the younger generation, and maybe even to give a new start to our devastated medical practice.

A doctor’s conduct in their clinical activity, their relationship with the patient, not only serve as a role model for new generations but are all elements that make up their way of being a doctor and they are inevitably influenced by their human nature. In this walk of life, whether a person has or does not have a spiritual attitude makes a very significant difference.

Not all medical students are attracted to surgery. When someone enters an operating room for the first time to attend an operation and sees the surgeon cut the skin of an unconscious patient with his scalpel, reactions differ: some people faint, some feel sick, some shudder horrified, others are fascinated and cannot turn their eyes away, and when they leave the operating room, they decide to become surgeons.

When the day comes that you find the scalpel in your own hands, everything changes. The gestures you have seen others make so many times become unexpectedly more difficult, you feel the instrument cutting into the patient’s skin, you must be precise, calculating exactly the weight of your hands in order not to cut too deeply and at the same time you must tie the blood vessels. Stress and tension are at their ultimate height, you do not feel up to the situation’s demands and want only to run away.

Yet with time, when you become an integral part of a surgical team, you cannot do without it. A sort of addiction to the operating room is created through the unique euphoria tied to the surgical act – to the tension, the fear of making a mistake and at the same time the realization that you are doing something indispensable to the health of the patient.

I may be biased because this is my specialty, for I do not believe I am wrong in saying that all surgeons are convinced that theirs is the most wonderful job in the world.

It is an occupation that is part craftsman and part intellectual, characterized by a direct relationship between cause and effect, between what you are doing and the result of your actions [1]. At times this is marvelous, but it can also cause despair according to the outcome of the patient. After a complex surgery, those who intensely experience their profession cannot but mentally repeat every step, every movement of their hands, every stitch, and immediately internalize where complications may arise. This is why one should never make decisions without listening to the opinion of the surgeon who has performed the operation, even though in most cases today postoperative problems are no longer tied to surgical technique but to infection or metabolic disturbances. The surgeon, more than anyone, will know how to anticipate the problem, make a diagnosis, and find the possible solution. In my case, whenever problems arise, I go to the patient’s bed at night when the hospital activities slow down, and stand there alone, searching my thoughts for the intuition that may lead me to the solution of the patient’s problem. This ritual has often enabled me to find a solution. At other times I have agonized, unable to find the right answer. In any case, this bedside visit has been a way for me to renew my bond with the ill person near me and my truest motive for having decided that one day I would become a doctor.

Combining faith in medicine, conceived of as mission, with a spiritual vision of life has both advantages and disadvantages.

“You are more useful to your patients if you spend your time in the intensive care unit rather than praying for them at mass” a friend, a believer in his own way, always told me when I arrived later than usual at the hospital on Sunday morning. For me, however, that small weekly ritual was part of my way of being a doctor. And still today, I am convinced that prayer can have a role in treating a patient. I also believe that it is not possible to speak of a difference between believers and nonbelievers when it comes to equal commitment, preparation, and sincere attachment to patients’ fate, just as faith alone does not provide additional reasons for assisting the sick. The difference is not in the operating room or in a doctor’s excellence but in the interpretation of his or her work and general approach to life. While being a believer does not influence the capacity or commitment that everyone has to their profession, it has a lot of relevance when facing a sick person every day.

Still, the ideals that inspire the believer when faced with diseases are not so different from those of a nonbeliever like Che Guevara, who in the diary he kept as a guerilla fighter wrote: “[. . .] the doctor performs an extraordinary function, not only because he strives to save lives [. . .] but because his task is also to sustain the sick person emotionally and make him feel that there is someone beside him who is striving to alleviate his pain, and that this person will stay beside the wounded or sick so long as he hasn’t been healed or the danger has not passed [2].”

There are many other examples. In Buddhism, the Dalai Lama teaches, quite poetically, that our behavior during life should be marked by love towards everything around us because every living creature – in the cycles of reincarnation – has at some time been our mother and, therefore, for every living being, we must feel the same love that is felt for a mother [3].

Solidarity, love, and compassion are ideas that are repeated in the gospel of the Christians, in the words of Che Guevara, and in the affirmations of the Dalai Lama: different paths, different ethics, but similar conclusions. I am convinced that it may be easier for the believer to adhere to the mission that ought to mark the work of every doctor, because it mirrors an act of faith in the Bible. For a nonbeliever it is a matter of adhering to a scale of values that has become part of his identity. For this reason, once these values are set, they cannot be betrayed without being false to oneself. Although equally committed and dedicated to one’s work and the health of one’s patient, the believer’s path is to some extent easier to follow.

The one real difference between the believer and the nonbeliever is the concept of compensation in the afterlife, something altogether absent from the nonbeliever’s perspective. For the believer, the final judgment on one’s actions, as doctor and human, will be from God, not from other peers. If s/he has acted in the interest of fellow humans and to alleviate the suffering of others, s/he will be rewarded in the afterlife. This is true not only for Christians but for all the religions that link one’s fate in the afterlife to one’s actions during life [4].

In this case, too, one can conclude that though equally committed, the believer is in some way helped while the nonbeliever is supported only by solid personal convictions. Belief in an afterlife represents an important resource for a doctor. While suffering is difficult to accept, death at the end is not only part of the natural biological cycle but represents a moment of passage, or rather the beginning of a new existence, whatever one’s religion. The moment of separation brings great grief to the family, but for those who believe in a monotheistic religion it represents at the same time the hope of rejoining the Father – or for a Buddhist the conclusion of a phase of existence in the cycle of divinity that is in each of us.

In the vision of the nonbeliever, on the other hand, with the end of life everything is over, the cycle is completed and the few remains left on earth will be visible only in the DNA passed to one’s children, or in cases of particularly illustrious men in the ideas or works left behind. For this reason, when medicine fails, the effect of death is even harsher; nothingness and the sensation of defeat cannot be alleviated and are, therefore, unacceptable. Still, there is an element of relief for everyone, even for nonbelievers. When the life of a sick person, forced to enter a hospital, comes to an end, the grief linked to the idea of loss is mixed with a sense of relief from suffering. The family and the doctor themselves are able to begin a new phase, that of mourning and, then, of remembering the positive images of the journey traveled with the departed person.

Finally, an allusion should be made to the role of prayer in relation to medicine [5]. Diverse and in-depth scientific studies have documented significant differences in the journey to healing between patients who trusted in prayer as well as medical care, and patients who did not. The journal Lancet, in June 2005, presented an interesting study, conducted with rigorous scientific methods on the impact of “noetic therapies,” that is therapies that do not resort to drugs, surgery, or other tangible interventions. One of these “therapies” is prayer and, in relation to the impact it can have on the health of a sick person, the study cites an analysis of the data from 393 patients in a heart failure unit [6]. All of them had signed a consent form when they entered the hospital in which it was explained that some of them would be assigned to a group of believers who would pray for their recovery. The patients would not know if in addition to the care of the doctors they were also receiving the prayers, yet in the group which had received them there was a 36% reduction in complications, a result which was certainly surprising but whose mechanisms are unknown to science.

Another scientific analysis, published in 2000, reported that 57% of the studies conducted on this subject demonstrate that prayer plays a role in healing. It does not matter what the religion is: this phenome is observed among Buddhists, Muslims, Christians, Jews, and followers of Confucius. It is a fact that does not have a clear explanation, and the interpretations vary depending on whether the analysis is done by skeptics or believers. In the first case, it is thought that recourse to prayer, to music, or a faith healer can lead to a physiological reaction like vasodilatation which can improve the patient’s health [7]. For someone who believes in God, on the other hand, the benefit is attributed to a plea offered to God and His response in a moment of need, a sign of His immense goodness. As far as I am concerned, when I realize that everything possible has been done to heal a patient, but nothing is working, I always advise family members to pray and do the same myself.

During the three years that I worked in Palermo, Sicily, a young woman in a coma from fulminant hepatitis was admitted to our transplant center. In most of such cases, the only thing that can save the patient’s life is a liver transplant. Requests at the national and European levels were made, so that the first liver available for transplantation would be given to this patient. Alas, the only liver available was that of an 80-year-old man who died falling from a tree. The advanced age of the donor and the trauma he had undergone meant the organ was not ideal for a woman under 30, but the few hours that she had to live did not allow any hesitation. Our team flew to Florence to remove the organ and after a few hours we did the transplant. Unfortunately, the woman developed a severe infection, and the transplanted liver could not function. The clinical picture was critical; despite all our efforts, the woman’s condition continued to worsen. She was in a coma, kept alive by a respirator, dialysis, and a complex machine called an “artificial liver,” in addition to the drugs used to combat the cardiac insufficiency. The grave infection, due to bacteria resistant to most antibiotics, and the lack of function of her transplanted liver, were extinguishing her life. If any of these treatments had been stopped, she would have died in a matter of minutes. There were no scientific guidelines remaining to justify continuing. I knew this, and I saw it in the eyes of Cataldo Doria, the surgeon I have worked with for 15 years and whom I trust the most. The only thing to do, at least for me, was to ask for help with prayer. I no longer pray as I did as a child, but I have established a daily dialogue with God, a higher being who accompanies me during my days and to whom I can turn at any time, to listen, and to also find strength and comfort when I do not find these things inside me. It was in exactly this sort of meditative moment that everything became clear: we had to try a new transplant. Against every expectation, this turned out to be the right choice. After 5 weeks of intensive care, the patient woke up during Christmas week and could finally embrace her five-year-old son. At the beginning of February, she returned home. It may have been luck or sheer coincidence, but for me there was a sign which gave me the determination to go ahead, listening more to my conscience than to what my rational mind was telling me.

Now, several years later, I still get regular news from that woman who has resumed a normal life, forgetting as time passes how she had almost died. She was certainly helped by the perseverance and tenacity of the doctors, but I do not exclude the possibility that her guardian angel also played a part.

 

Conclusion

In surgery, when performing the complex procedures described in this book, the surgeon should also bring his/her faith – whatever that might be. It always helped me. 

 

References

1. Gawande A. Complications: A Surgeon’s Notes on an Imperfect Science, Picador USA; 2003
2. Che Guevara. Radical Writings on Guerrilla Warfare, Politics and Revolution, Filiquarian Publishing; 2006
3. Dalai Lama, An Open Heart, Little Brown and Company, Boston, New York, London; 2001.
4. Pope John Paul II, Evangelium Vitae: The Gospel of Life, Pauline Books & Media, Vatican City; 1995.
5. Roberts L, Ahmed I, Hall S, Sargent C. Intercessory prayer for the alleviation of ill health. Cochrane Database Syst Rev. 2000;2:CD 000368.
6. Byrd RC. Positive therapeutic effects of intercessory prayer in a coronary care unit population. South Med J. 1988;81:826–829.
7. Krucoff MW, Crater SW, Gallup D, Blankeship JC, Cuffe M, Guarneri M, Krieger RA, Kshettry VR, Morris K, Oz M, Pichard A, Sketch MH Jr, Koenig HG, Mark D, Lee KL. Music, imagery, touch, and prayer as adjuncts to interventional cardiac care: the Monitoring and Actualisation of Noetic Trainings (MANTRA) II randomised study. Lancet. 2005;366:211–217