Serious Emphasis on Spirituality
Spiritual Resources in Family Therapy.
Froma Walsh, editor.
New York: Guilford Press, 1999.
301 pp. $35

The words spiritual and spirituality continue to find their way onto the covers of an ever-increasing number of books, in a surprising variety of genres. These concepts are as striking for their multiple, ambiguous meanings and applications as for their current hold on the American imagination. In tandem with the flowering of popular texts that examine traditional, nontraditional, and downright bizarre spiritual experiences, beliefs and practices new academic disciplines attempting to understand just what is meant by contemporary use of the term spirituality are flourishing. Within existing disciplines scholars are racing to examine the spiritual dimension.

Froma Walsh's Spiritual Resources in Family Therapy reflects both a desire to develop these as-yet fuzzy concepts, as well as to expand the literature at the intersection of religious and spiritual matters and clinical mental health. The book contributes to an emerging body of writing intended for persons who are neither casual consumers of popular, unself-critical self-help spirituality texts nor students of religious or theological studies, but who have a professional interest in the impact of religion and spirituality on the lives of patients and clients.

Walsh's emphasis, family therapy and systems theory, creates a text that is more specific than many of the generalized works crowding bookshelves today. A social worker with a doctorate in social work and a family therapist, Walsh has published extensively on resilience, family beliefs, and spirituality. Expanding upon her earlier forays in this area, and assembling the contributions of others in her field, Walsh describes this collection "as a sourcebook to inform and inspire mental health, health care, pastoral, and human service professionals of all disciplines about this vital dimension in clinical work with couples and families" (p. ix).

Not unexpectedly, contributors are mostly therapists in family systems work. They all have a generally positive perspective on the use of either the clinician's or the client's spirituality as a therapeutic resource. Though few give more than a hint of their own religious context, in general Walsh's collaborators seem to take a liberal, religious humanist stance. While liberal is often equated with tolerant, the failure to include diverse perspectives can lead to unwarranted universalizing of the particular. Taken as a whole, the book does appear to lack a certain critical distance from its own general consensus on what constitutes the core of spirituality; I experienced it as less pluralistic than it purports to be (p. ix). Having said this, both Walsh and her collaborators make frequent reference to their awareness of the elusiveness of objectivity. The difficulty perhaps reflects more the slipperiness of the topic than anything else.

The lack of a variety of religious and spiritual perspectives may result from the fact that only three of the 21 authors explicitly identify affiliations with or backgrounds in religious or theological studies. This is not to say that significant religious or theological perspectives are not articulated. Wayne Muller (chapter 7) offers a meaty Buddhist theological reflection on life, suffering, and healing. Still, in a culture both fascinated by and remarkably ignorant of the complexities of religious and spiritual matters, and in light of the confusion in mental health disciplines about the terms religious and spiritual (evidenced to some extent in Walsh's preface and overview), I would have hoped for more collaboration from persons working on both sides of the religious/spiritual-clinical mental health divide. One of the disastrous failures of professionals working in these disciplines has been an exasperating inability for so many of us to be in conversation with each other so that we may embrace the connections between these fields without losing the distinctiveness proper to each of them. This theme is echoed by William Doherty in chapter 10. The result has been an unfortunate polarization between sides who imagine and project onto, but do not engage each other fruitfully. To some extent this text misses the opportunity to counter this tendency. The absence of more explicit perspectives of persons in longstanding religious and theological bridge disciplines, such as pastoral counseling or pastoral psychology, is unfortunate. Their absence contributes to the widely held sense in secular psychological circles that persons who have divorced themselves from traditional religious perspectives and communities (those who are "spiritual" rather than "religious") are more able to objectively discuss spiritual and religious matters.

This observation aside, the essays are thought-provoking forays into uncharted territory. Walsh's introduction and overview are followed by Loraine Wright's engaging discussion of the significance of family narratives and beliefs. As do many other contributors, Wright uses case material to enliven her essay. Chapters 4 through 8 address religion and spirituality in diverse populations, including African-American, Latino, the poor, Jewish, and (to a lesser extent) Buddhist and feminist. Because the term spirituality often signals a decontextualization of certain kinds of beliefs and practices- which are recast as normative and universal (quite often religious humanist positions)- Walsh's text is head and shoulders above others because of its inclusion of a variety of perspectives rooted in concrete religious traditions. I was, however disappointed that relatively little attention was paid to the relationships of gay, lesbian, bisexual, and transgendered persons to their families and to their religious and spiritual traditions. Herbert Anderson sums up the first half of the text with his essay, "Feet Planted Firmly in Midair: A Spirituality for Family Living," which reminds readers why family and systems perspectives, oriented as they are to relationality and to the complexities and paradoxes of family relationships, are particularly suited to the consideration of a similarly paradoxical religious and spiritual dimension.

Chapters 10 through 16 offer practical ideas about incorporating religious and spiritual matters into clinical practice. Janine Roberts, well-known for her work in family rituals, offers an excellent point of departure for integrating religious and spiritual matters into training settings. Melissa Griffith's "Opening Therapy to Conversations with a Personal God," discusses four common mistakes therapists make when attempting to address religious and spiritual matters:

"I know what God is like for you because …

… I know your religious denomination;

… I know what your language about God means;

… your image of God is a reflection of your early attachment figures; and

… I know what God is like and you need to know God as I do."

All of us, whether we risk addressing religious and spiritual matters in our practice or not, should have these mistaken assumptions pasted on our walls.

I was most compelled by Griffith, and by William Doherty's essay "Morality and Spirituality in Therapy". After helpfully identifying himself and his philosophical commitments (a practice that relativizes his perspective) he offers a clearly articulated and well-reasoned model for how to write, think, and talk about the intersection of clinical mental health and religious and spiritual issues. Doherty identifies one of the most significant problems in the cultural conversations about spirituality: the term is used so broadly as to render it meaningless. Through uncritical overuse, spirituality often comes "to encompass most of the mental health domain. . . . A term that means too much soon means nothing" (p. 180). His solution is to conceptualize three domains of discourse-clinical, spiritual, and moral-each with its proper concepts and emphases, and its proper limits. While these domains remain distinct, they are not mutually exclusive, and clinicians (as well as religious professionals) are constantly negotiating among them. Doherty's short epistemological essay is the most significant contribution of the entire compilation because it offers a way for clinicians of many different perspectives (whether they themselves are religiously or spiritually inclined or not) to establish ground rules for talking about the rich theoretical and clinical material presented here. His system gives different meaning systems some common ground, and may be the anxiolytic so many mental health professionals need before delving into religious or spiritual matters. Indeed, his essay would provide a useful contextual frame for the rest of the essays, including Walsh's.

In all, Walsh's text is a welcome addition to clinical care. Many of the essays shine (especially those that emphasize hands-on clinical examples) and where they falter they reflect the larger confusion about the subject matter itself. Several of these essays would work well in a clinical training setting, and the book as a whole accomplishes its goal of opening family therapy practice to an explicit consideration of religious and spiritual matters.

Window to the East
Confucian Bioethics
Ruiping Fan, editor.
Dordrecht, Boston, London: Kluwer Academic Publishers, 1999.
284 pp. $135

A century ago a book of essays on Confucian bioethics would probably have been unthinkable. At the end of the nineteenth century, many Chinese intellectuals rejected Confucianism (the cultural mainstay of East Asian civilization for 2000 years) as a relic of a feudal age, holding China back, and keeping her in thrall to the West. In the middle of the twentieth century, much of traditional Chinese culture including Confucianism, fell victim to Mao's Cultural Revolution (1966-1976). Remarkably enough, in the last twenty years, Confucianism has re-emerged in China and the West, as this fine book attests.

Confucian Bioethics contains ten essays by ten authors jointly examining a particular bioethical issue, first by using key ideas from the Confucian tradition, then showing the vitality and coherence of the tradition in the present age. (This latter point is not to be taken lightly. In 1997, for instance, Lionel Jensen argued in Manufacturing Confucianism that a coherent Confucian tradition doesn't exist-"Confucianism" being a construct devised by Jesuit missionaries in the sixteenth century. This argument has won an American following.) The essays in the first section introduce some key Confucian ideas. Those in the second and third sections apply these key ideas sto topics such as euthanasia or medically futile procedures. And those in the fourth section look at the way ideas about justice and the good life affect health care policy.

In his introduction, Ruiping Fan reminds us that medical decisions, and the bioethical principles on which they depend, are rarely value neutral. Despite the Enlightenment dream of arriving at such principles by reason alone, they always reflect culture-specific values. Therefore, ethicists and health care professionals would do well to understand the value systems of different cultures, such as Confucianism, if they are to make responsible decisions about health care in a multicultural age.

In the first section, Peimin Ni and Ellen Zhang challenge the old stereotype of the Confucian as a pale intellectual who practices self-cultivation to the detriment of bodily health. On the contrary, Confucians repudiate any mind-body dualism, be it Cartesian or Platonic. For the Chinese in general, and Confucians in particular, the word xin, actually means both at once, so that "for Confucians xin is not entirely incorporeal." The body is not, therefore, a container for the self, but the embodied expression of one's personhood. Through the body, one relates to other persons. Among those to whom one relates, foremost are one's parents, so the primary human relation is a blend of filial piety and parental love. Thus when Confucians advocate self-cultivation, they advocate harmony, first between the body and the heart/mind, and second, between the body-and-the-heart/mind and the "totality of Heaven-Earth, humanity, and myriad things."

In the second section, Ping-Cheung Lo, George Khushf, and Edwin Hui then ask how Confucians think about euthanasia, or about cases in which certain medical procedures (e.g. maintaining life-support) are deemed futile. In the third section, Xunwu Chen, Jing-Bao Nie, and Ronald Carson discuss human experimentation and organ transplantation. All authors in these two sections dissent sharply from what they take to be typical Western points of view. If, they write, a Westerner says that a patient is an autonomous moral agent with the power to decide his or her fate in cases of euthanasia or medically futile procedures, a Confucian will ask whether that decision ensures "social stability and harmony in human relations," or whether it promotes the cardinal Confucian virtues of humanity and righteousness. In particular, a Confucian son or daughter practicing filial piety might well "reject the determination of medical futility" and "request everything be done for their dying parent." Likewise, with human experimentation. If, argues Chen, Westerners are utilitarian, ready to accept such experimentation, if it leads to the greatest good for the greatest number, a Confucian will likely reject it on the grounds that it does not reflect "righteousness in line with humanity." Nie and Carson argue that we can learn something about organ transplantation by looking at the ancient, and seemingly bizarre, practice of administering "human drugs," especially medicines made from human flesh.

In the fourth section, Qingjie Wang and Ruiping Fan tackle health care in general. Again appealing to the idea of filial piety, Wang challenges the view taken by some Western philosophers that children are no more obligated than anybody else to care for elderly parents. Fan rounds out the book by playing off Confucius against John Rawls (among others). Granted, we live in a pluralistic age, in which different persons and groups debate often incommensurable, views of what constitutes the "good life." But if Rawls argues that the just society is one which takes no sides in these debates, Fan contends that such neutrality is illusory. For any presumed neutral stance encodes one view or another of the good life willy-nilly, which it then enforces surreptitiously. Better to state one's views openly, as does Confucianism, and then go head-to-head (presumably in a spirit of humanity and righteousness) with the views one deems wrong. On health care, argues Fan, a Confucian will accordingly oppose a government-based system, and advocate a "family-centered and community-centered view of just health care."

The weakness in all this, of course, is that it unduly simplifies the differences between Confucian (or Chinese) and Western views. Not all Westerners are utilitarians. Nor do Platonism or Cartesianism exhaust what the West has to say about the relation between mind and body. (Aristotle, Heidegger, and the Bible might give dualists a run for their money, and, in the bargain, give us fresh purchase on Confucius.) Still, the book belongs to a growing list of texts, including Hall and Ames's Thinking Through Confucius (1987) and de Bary and Tu Weiming's Confucianism and Human Rights (1998), which are opening up new avenues of dialogue between West and East. In an era when health care is a hotly contested topic of discussion, Fan's book is an invaluable resource that has much to teach us.

Stories into Myth
The Blood of Strangers: Stories from Emergency Medicine.
Frank Huyler.
Berley: University of California Press, 1999.
154 pp. $19.95

"That," said a student, of Kate Chopin's The Story of an Hour, is "a haiku of a story." Several of Huyler's pieces in The Blood of Strangers share the elegance, economy, and emotional power of the haiku. In one, a male patient who had been raped as a child begs Huyler not to insert a Foley catheter. Because he believes the patient has a ruptured spleen, Huyler orders the Foley anyway. The patient "goes somewhere else, he vanishes. His face is great distance." Huyler is almost gloating when he confirms his diagnosis and the patient agrees to surgery: "Do what you want to." The piece concludes, "Discharged, five days later, in good condition" (114). Called, simply, "Power," this story is an updated, shorter version of William Carlos Williams's "The Use of Force."

"The Short Arm of Chromosome 4" and "I'm Driving" are also haiku-like, the latter so complicated it almost doesn't fit the haiku mold. It contains Huyler's residency-required research project; memories of his grandmother's suicide; his visit to an Arizona graveyard full of metal-crafted plaques, chimes, cages, crosses, and, at the end, a focus on a single "study subject" (another suicide) so harrowing that it leaves us chilled.

Clearly, Huyler has read the works of his American predecessors, especially Williams, Richard Selzer, and perhaps even John Stone, whose essay "An Infected Heart" has its emergency room/ICU counterpart in Huyler's opening story, "The Unknown Assailant." Bound by his pledge of beneficence, Huyler muses over the irony of helping a patient accused of killing two people.

These stories are rife with ethical dilemmas, and they remind us how intertwined the lives of physicians, patients, and families are. In most Huyler discovers (perhaps through the act of writing) incidents that define or enlarge an individual's life. In "I'm Driving," for instance, Huyler defines the lives of the suicides he is studying, enlarging their stories into myth by incorporating photographs, a visit to the graveyard, and a childhood dream of his own.

With the exception of the opening piece, the stories are arranged chronologically, beginning with three from Huyler's medical school years. Most however, are based, on incidents that occurred during his residency and fellowship years- only in the last one does he state that he has become the attending physician in the emergency room. Yet readers who come to The Blood of Strangers looking for the adrenaline rush typical of the emergency room will find it in only three of the short pieces; to Huyler's credit, he has avoided writing a collection that has the feel of television's ER. But everyone who loves a good story, and everyone who likes the challenge that oblique storytelling provides will find much to admire. Although the focus of the stories is almost equally divided among patients, other physicians or health care providers, and Huyler himself, all are filtered through Huyler's inquisitive, carefully observant, and detached eye. Huyler sets information before us and leaves the reader to make connections and find meaning.

Several devices mark Huyler's style. In "Black Bag," set on the first day of anatomy lab, the detail of his lab partner Tony's bag-his name printed on the handle, a gift from his family-expands our understanding of Tony's background at a stroke. Huyler also introduces a subplot to "Black Bag," in which a university professor has manic episodes. He sets up each story and its details to comment on the other and on what he himself is learning. In "Black Bag," he finds common motifs in secrecy and drugs: the professor tries, through proper medication, to keep her manic life secret, while Tony's secret life comes to light after he kills his lover with an overdose of migraine medication.

It becomes our job as readers to find the connections Huyler suggests. In "The Dead Lake," Huyler combines the stories of three patients-a young woman dying from a bullet in her brain, a man who has attempted suicide and blown away part of his jaw, and the young woman's father, an alcoholic, who receives his daughter's liver. Huyler ties their stories together and to his own history through family photographs that recall childhood, and his telling is so unobtrusive that we almost miss the identity of the liver's recipient.

Despite Huyler's apparently simple method of telling stories, we learn much about him and those around him, especially Ruth, the neurosurgery attending, Rosa the surgery resident, and three male attending physicians. We see quite clearly how Huyler's age affects his attitude toward his patients, from his hesitation to withdraw life support from a cowboy younger than himself to his missed diagnosis, in "Liar," of a sixty-year-old woman described as "Thin, old, wizened…. A sponge, an absorber of energy and time, for unclear useless ends" (135). This candor amazes. Huyler also openly describes his anger at a family's "glib revision" of their criminal-father and his dread of the patient who will require careful attention throughout a very long night.

One of the deep satisfactions to be found in this book is that we witness Huyler's transformation into a mature physician. In "A Good Scar," Huyler describes his devotion to a wound and his recognition, almost as an afterthought, that he's sewing up an unconscious person. In the years between "A Good Scar" and "A Difference of Opinion" Huyler comes to see his patients and to see himself in them-that is, he learns he could be them, and this recognition changes his attitude toward their treatment. In "Prelude," the first of the medical-student stories, and the book's last piece, "Time," Huyler steps outside, "emptying myself," as he puts it, when things get really difficult. Yet the Huyler of "Time" is much changed from his young self. Outside the ER he is startled by a noise behind him, then relaxes as he realizes it's "just the nurse, Susan." The phrasing makes us pause and reconsider. In "Prelude" time stretches out before Huyler like the "pine forests that stretched for miles into the distance at the edge of town"; by age thirty-two and the story "Time," he recognizes that wingèd chariot we all fear.

Inevitably, Huyler's stories comment on how medicine is practiced in an age of managed care. In "A Difference of Opinion" two attendings disagree on how to treat a twenty-eight year-old patient (Huyler is himself then only thirty) who has been in the ICU for nearly a month. One attending wants to do everything; the other thinks all treatments should be stopped. Huyler must participate in this divisive approach to the patient, who is unaware of the work going on around him:

Mr. Johnson . . . had unfailingly robbed me of sleep, and I had come to dread him. I knew him intimately, had examined him dozens of times, turned him over to look at his back, put my gloved finger in his mouth, in his rectum, into the interior of his chest cavity, and I had never once exchanged a single word with him. He was gone from the waking world, as nearly dead as a human being can be, lying at the edge but never quite crossing over, his body, his animal self just strong, or not strong, enough.

Six months later, off the ICU service and walking back to the ER after lunch, Huyler is shocked to recognize Mr. Johnson standing in the pulmonary clinic:

"Mr. Johnson?" I asked tentatively, stepping in through the clinic door.

He looked up at me from the newspaper.

"Are you Mr. Johnson?" I asked, beginning to feel foolish.

"Yes," he said, looking at me suspiciously. "Do I know you?"

This closure beautifully illustrates Huyler's deep need to know his patients as individuals, a need not at all characteristic of managed-care medicine.

Huyler's work has the evanescence and the specificity typical of superior writing, and he knows the important questions to ask. One reviewer of The Blood of Strangers hoped Frank Huyler would, like Chekhov, practice medicine only part-time and take more time for writing. I hope Huyler will ignore the suggestion; he is obviously doing both quite well. Patients need doctors like him in ERs, as mentors for those who work under them, mentors who can help young doctors to become inquisitive, observant, caring physicians.