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From Luke’s Journal May 2025 | Vol. 30 No. 1 | MIMBY

This article examines the ethical challenges of healthcare professionals providing spiritual care for their patients.

^[1] This will be done via a threefold structure: Ethics of healthcare professionals providing spiritual care; ethics of Christian healthcare professionals providing spiritual care and an applied ethic of Christian healthcare professionals providing spiritual care.

Healthcare professionals providing spiritual care is perhaps at best confronting, at worst anathema. Certainly, since the Enlightenment, a separation between science and spirituality has become normal in the Western world.^[2] Yet, the earliest copies of the Hippocratic oath open with reference to the divine, specifically the Ancient Greek gods Apollo, Asclepius and Panacea. These references to the divine are reflected in the traditional symbol of medicine being a divine sceptre, the caduceus.

However, medicine has evolved profoundly since Hippocrates. So, is it appropriate for modern healthcare providers to provide spiritual care?

Modern medical ethics are built on four pillars – beneficence, nonmaleficence, autonomy, and justice.^[3] These pillars neither endorse or prohibit the provision of spiritual care. However, before further engaging with the ethics of spiritual care in the midst of dementia, it is critical to define ‘spirituality’.

This is no easy task as there is no agreement in the literature about what spirituality is.^[4] Historically, spirituality was seen as synonymous with religion but many modern definitions overtly separate spirituality from religion.^[5] Given Luke’s Journal is an Australian publication and the focus of this article is dementia which is primarily experienced by older people, this paper will use the Meaningful Ageing Australia^[6] definition of spirituality:

Spirituality is the way we seek and express meaning and purpose; the way we experience our connection to the moment, self, others, our world and the significant or sacred.^[7]

“Furthermore, holistic health requires looking beyond the biomedical to include spiritual health.”

This definition emphasises that all people are spiritual beings with spiritual needs. Furthermore, holistic health requires looking beyond the biomedical to include spiritual health.^[8] Finally, there is overwhelming evidence for the impact of spirituality on health for people generally,^[9] and for older people specifically.^[10] Please forgive the pages of references but this is only a taster^[11] and I wanted to emphasise the sheer quantity of peer reviewed research which highlights the importance of spirituality in terms of health. If you prefer a book the key tome is the Handbook of Religion and Health.^[12]

Finally, there is strong evidence showing that patients want their medical professionals to engage with and ask about their spiritual health.^[13]

Given the weight of this evidence: The question is not “Is it ethical for healthcare professionals to provide spiritual care?” but rather “How can healthcare providers provide ethical spiritual care?”

Ethics of Christian healthcare professionals providing spiritual care

Having demonstrated the importance of healthcare professionals providing spiritual care, this section explores the ethics of Christian spiritual care for medical professionals.

Being a Christian ethic, it is critical to summarise the Biblical teaching around spiritual care. Christianity holds to a spirituality of conversion and disciple-making as the only way to the good life both now and eternally. An interesting presentation of this reality comes from the atheist Penn Gillette, of Penn and Teller fame – https://www.youtube.com/watch?v=VF2vi9h9B1Y

This is not to suggest spiritual abuse is not possible and Biblically offensive,^[14] but to quote Penn ‘how much do you have to hate someone’ to believe in the reality and importance of relationship with Jesus and not share that?

The topic of relationship with Jesus brings up the question: Is relationship with Jesus possible for people living with moderate to advanced dementia and can dementia take away a Christian’s relationship with Jesus?

“I have heard theologians argue that salvation is not available to people living with advanced dementia on the basis that conversion requires cognition.”

I have heard theologians argue that salvation is not available to people living with advanced dementia on the basis that conversion requires cognition. I believe this position neglects two critical points:

1. Salvation is a work of God alone.
   
2. Salvation is not simply a cognitive process. If this was true, then no one would be saved as we all forget God on a daily basis!

As I read the Bible, dementia does not stop a person coming into relationship with Jesus. A more detailed theology of conversion in the midst of dementia is outlined in Wormell’s short book.^[15]

If relationship with Jesus is available to people living with dementia, the question becomes “Can dementia take away a person’s salvation?” As a chaplain, when I am asked this question I reply: “Is Christianity based on me and my cognition or God and His love?” A fuller examination of this can be found in Swinton’s pivotal text.^[16]

Therefore, I believe there is both a medical and Biblical imperative for Christian medical professionals to provide spiritual care to their patients, but such care must not be abusive.

Applied ethic of Christian healthcare professionals providing spiritual care

Spiritual care within the context of the power differential of medical professional and patient is not simple. However, I would suggest that ‘simple’ is rarely a part of healthcare. For example, treating patients whose decisions are clearly harming their health is not even remotely simple.

I suggest the path forward is based on the principles of ethical medicine – beneficence, nonmaleficence, autonomy, and justice:^[17]

Beneficence – looking for appropriate ways to provide spiritual care. From a Christian perspective this will mean praying for yourself, your engagement with patients and for your patients. Practically it may mean asking not simply about their blood pressure and bowel motions but their spiritual health.

Nonmaleficence – not forcing your spirituality onto a patient. This is a Biblical position, as Jesus never forced people into relationship with Him.

Autonomy – recognising spirituality is a choice. Scripturally this means remembering conversion is a work of God, we cannot force it.

Justice – means we do not neglect spiritual care of people where it is challenging – for example people living with dementia.

Having engaged with these pillars of ethical medical practice, it is important to recognise ethical spiritual care is not easy. As such I want to suggest three further principles which may help:

1. Boundaries – It is critical to know and actively guard your boundaries: personal, professional and organisational.
   
2. Referrals – A key tool to protect boundaries while still providing care is providing referrals. Just as a GP might refer a patient with a sore jaw to a dentist, consider referring a person in spiritual distress to a spiritual care expert.
   
3. Professional development – Just as with other aspects of your practice, it is critical to continually invest in your professional development. For example, you could consider reading some of the articles previously cited about the importance of spirituality for people’s health.

My hope is that this article has helped you to think about the ethics of spiritual care as a Christian healthcare worker and given you some tools to help you provide ethical spiritual care in this context. If you are interested in Christian ministry with older people and people living with dementia more generally, you can watch my video 5 tips for engaging with older people on YouTube, and keep an eye out for my book ‘Priceless People.’ due for release by Christian Focus Publications in mid-2025.

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1. As such it builds on the previous Luke’s Journal article Dementia and Faith – Boland, B. (2024) Jesus and Dementia. Luke’s Journal. 29(3), 19-24.

2. Suran M. The separation of church and science. Science and religion offer different worldviews, but are they opposite or complementary? EMBO Rep. 2010 Aug;11(8):586-9. doi: 10.1038/embor.2010.106. PMID: 20661245; PMCID: PMC2920436.

3. Varkey B. Principles of Clinical Ethics and Their Application to Practice. Med Princ Pract. 2021;30(1):17-28. doi: 10.1159/000509119. Epub 2020 Jun 4. PMID: 32498071; PMCID: PMC7923912.

4. A good introduction to defining spirituality can be found at https://meaningfulageing.org.au/definitions/

Academic discussions of the challenge of defining spirituality include:

Ajam Zibad, H., Mohammadi Shahboulaghi, F., Foroughan, M., Rafiey, H., & Rassouli, M. (2016). What is the meaning of spiritual health among older adults? A concept analysis. Educational Gerontology, 42(12), 795–808. https://doi.org/10.1080/03601277.2016.1205349 p. 796.

Harrington, A. (2016). The importance of spiritual assessment when caring for older adults. Ageing and Society, 36(1), 1–16. https://doi.org/10.1017/S0144686X14001007 , p. 1-2.

Toivonen, K., Charalambous, A., & Suhonen, R. (2023). A caring and living environment that supports the spirituality of older people with dementia: A hermeneutic phenomenological study. International Journal of Nursing Studies, 138, 104414–104414. https://doi.org/10.1016/j.ijnurstu.2022.104414 p. 2.

5. Agli, O., Bailly, N., & Ferrand, C. (2017). Validation of the Functional Assessment of Chronic Illness Therapy—Spiritual Well-being (FACIT-Sp12) on French Old People. Journal of Religion and Health, 56(2), 464–476. https://doi.org/10.1007/s10943-016-0220-0, p. 464-466.

Casanova, G., Machado, I., & Melo, S. (2024). The role of spirituality in later life: a study of older adult university students in Portugal. Journal of Religion, Spirituality & Aging, 36(3), 309–332. https://doi.org/10.1080/15528030.2023.2216157, p. 310.

Martha R. Crowther, Michael W. Parker, W. A. Achenbaum, Walter L. Larimore, Harold G. Koenig, Rowe and Kahn’s Model of Successful Aging Revisited: Positive Spirituality—The Forgotten Factor, The Gerontologist, Volume 42, Issue 5, 1 October 2002, Pages 613–620, https://academic.oup.com/gerontologist/article-abstract/42/5/613/653590?redirectedFrom=fulltext, p. 613-614m

6. Meaningful Ageing is the peek Australian body for spiritual care in later life

7. https://meaningfulageing.org.au/about/

8. Best MC. Spiritual Care in Palliative Care : What it is and Why it Matters. 1st ed. 2024. Cham: Springer Nature Switzerland; 2024.

Southard ME. Spirituality: The Missing Link for Holistic Health Care. Journal of Holistic Nursing. 2020;38(1):4-7. doi:10.1177/0898010119880361

9. Baetz, M. , Griffin, R. , Bowen, R. , Koenig, H. G. & Marcoux, E. (2004). The Association Between Spiritual and Religious Involvement and Depressive Symptoms in a Canadian Population. The Journal of Nervous and Mental Disease, 192 (12), 818-822. https://pubmed.ncbi.nlm.nih.gov/15583502/

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Lim, C., & Putnam, R. D. (2010). Religion, Social Networks, and Life Satisfaction. American Sociological Review, 75(6), 914–933. https://journals.sagepub.com/doi/10.1177/0003122410386686

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10. Agli, O., Bailly, N., & Ferrand, C. (2017). Validation of the Functional Assessment of Chronic Illness Therapy—Spiritual Well-being (FACIT-Sp12) on French Old People. Journal of Religion and Health, 56(2), 464–476. https://doi.org/10.1007/s10943-016-0220-0, p. 464.

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11. It is part of a literature review I am currently writing on spirituality and quality of Life in later life.

12. Koenig, H. G. (Harold G., King, D. E., & Carson, V. B. (2012). Handbook of religion and health (3rd ed.). Oxford University Press.

13. Belk, W. Balboni, T.A. (2024). ‘Impact on spiritual care on patient outcomes at the end of life’, in Spiritual Care in Palliative Care: What it is and why it matters? (ed) M. Best, Springer, p. 187-196.

Best, M. (2024). ‘The role of the doctor in spiritual care’, in Spiritual Care in Palliative Care: What it is and why it matters? (ed) M. Best, Springer, pp. 437-454.

Bradford, K.L. De la Cruz, H, & Delgado-Guay, M.O. (2024). ‘The role of religious belief in palliative patients, in Spiritual Care in Palliative Care: What it is and why it matters?’ (ed) M. Best, Springer, pp. 67-80.

Bussing, A. (2024). ‘Spiritual needs and spiritual wellbeing of palliative care patients’, in Spiritual Care in Palliative Care: What it is and why it matters? (ed) M. Best, Springer, p. 33.

14. Boland B. (2024). Should Urban Mission Include a Focus on Older People? Australian Journal of Mission Studies, 18(1), 51-55. P. 51-52.

15. Wormell, M. (2016). Coming to Christ in Dementia. Mountain Street Media.

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