By Michael Balboni

This is the first in a four-part series examining the social and historical forces that have led to the current divide between religion and medicine. Drawing on Peter Berger’s theory of plausibility structures (particular social processes that legitimize social beliefs and practices, giving them a matter-of-fact quality), this series will examine the driving factors behind the current state of spirituality in medicine. This post centers on the evolution of the hospital from the medieval period to the modern day, and how religion came to be of lessened importance in this setting.

Many modern American hospitals (especially in wealthy areas) are palatial and imposing, home to a wide variety of medical specialists and technologies. It can be intimidating to step into the imposing marble entryway of Dana-Farber’s Yawkey building or the labyrinth of Brigham and Women’s Hospital, the hospitals where I work, especially when one is facing a potentially devastating diagnosis. Patients of faith may also notice that for all their technological marvels, modern hospitals offer little by way of spiritual support to help them navigate their experience of illness.

This wasn’t always the case. During the medieval period, hospitals were primarily affiliated with religious organizations, who sought to ensure the comfort of patients and support them as they entered into right relationship with God in their last days of life.

During the Renaissance, the nation-state began to eclipse the Church as the preeminent institution in everyday life. Nations had a strong interest in maintaining the health of their members in order to ensure a robust economy and a well-functioning military, and so the all-purpose medieval hospital was splintered into institutions with somewhat overlapping functions: hospitals, hospices, asylums, and prisons. At the same time, the Protestant Reformation led to the restructuring of religious institutions in Europe and legislation that closed many monastic orders along with the hospital wards they ran. The new hospitals that emerged to take their place were frequently financed by local governments, and their primary purpose was to ensure a physically fit populace. [1,2]

By the eighteenth century, the Enlightenment emphasis on the powers of reason and science had transformed the hospital from a caring facility into a primarily medicalized space. The utopian hope in the ability of science to overcome illness and death (as well as the remarkable advances in this field) coincided with national concern about public health. Health became both an individual and social good, and death an undesirable outcome kept at bay through good health management. Hospitals came to focus on the physical recovery of diseased individuals, striving to become, what historian Guenter Risse calls, “houses of cure” that could overcome human mortality through the advance of technology. [3] While shelter, food, clothing, and moral rehabilitation still remained institutional goals, medical and surgical treatments became paramount.

One of the criteria for judging the performance of these fledging hospitals was mortality rates – how many of the admitted patients eventually died in the facility? While this doesn’t seem unreasonable at first glance, the emphasis on mortality rates discouraged hospitals from admitting those patients who were truly in dire need of care, instead allowing entrance primarily for young, otherwise healthy people with self-limiting ailments. After 1750, for example, the Royal Infirmary of Edinburgh was proud to consistently boast a low 4% mortality rate among its patients.[4] This was a major departure from the history practices of hospitals, which had sought to act as caregivers on the patient’s journey into the next life. Hospitals placed an emphasis on systematic clinical observations, treatment and experimentation with drugs, and bedside learning that transformed them into houses of teaching and research. Unsettlingly, people selected by academics for experimental management and teaching were segregated in teaching wards and subjected to postmortem dissections. [4]

By the Twentieth century, the transformation of hospitals from houses of care to institutions of science and technology was complete. During the so-called Golden Age of American medicine (roughly 1860-1960), hospital space was divided according to new medical specialties and equipment, and hospitals deployed cutting-edge technology such as clinical laboratories and x-ray facilities to improve diagnosis and treatment. Yet despite these advances, death remained an insurmountable obstacle, and so the reality of the end of life was swept under the rug. Hospitals transferred chronic and terminal individuals to newly-established nursing homes and hospices, and even concealed death’s presence through architectural designs that relegated the morgue and pathology departments to the basement. [5] Despite their apparent futility, deathbed rituals in modern hospitals include intensive care units that aggressively deploy medications and technology when the patient is near death, doggedly seeking to prolong life regardless of cost. [6,7]

Today, hospitals are part of a complex economic healthcare system that makes up one of the largest industries in the United States (employing one in ten Americans), and they need to navigate shifting economic structures, market forces, and healthcare policies. Driven by the demands of capitalism, hospitals are in competition with one another for “customers,” which has led to a large increase in the rates of outpatient services, pressure to decrease length of hospital stays, and emphasis on high-technological services in order to maximize income. Physicians within hospitals are increasingly finding that they need to negotiate a difficult balance between the needs of their patients, the restrictions of insurance companies, and the bureaucracy of hospital administrators.

Where is religion in all this? As Risse (1986) observes, while “the early Christian shelters provided great spiritual solace but minimal physical comforts….Modern hospitals, by contrast, have reversed this emphasis and now focus primarily on individual physical rehabilitation in more fragmented and depersonalized environments.” [4] For most religions, death is not an obstacle or an ending but instead a reorganization, and (we hope for many) an elevation in the way that an individual experiences his/her relationship with God and other people. Religions provide the tools necessary for patients to parse the meaning of their lives and make sense of death; religion also provides a rationale for providing medical care that has nothing to do with financial gain.

In sum, religious/spiritual support has historically been a crucial element of medical care, especially at the end of life. Medieval hospitals were often associated with monasteries or other religious organizations, and shepherding the dying into the next life was a vital part of their mission. By the Renaissance, the Reformation and the rise of nationalism had resulted in the state rather than the church being the central organizing institution of daily life, and hospitals experienced a push to keep mortality numbers low. The twentieth century saw the rise of advanced medical techniques and technologies, along with an increased push to sideline the reality of death and to maximize profits. These historical and social forces have led to a strongly decreased emphasis on religion in hospital settings.

In the next article in this series, we will examine the development of the physician’s role, and identify the features of medical socialization and identity that are inimical to the integration of religion/spirituality and medicine.

Enjoyed this article? Consider purchasing From Hostility to Hospitality: Spirituality  and Professional Socialization Within Medicine, to be published with Oxford University Press in summer 2018.

Bibliography:
[1] Grell O. The Protestant imperative of Christian care and neighborly love. In: Grell O CA, ed. Health Care and Poor Relief in Protestant Europe 1500-1700. London: Routledge; 1997:43-65.
[2] Orme N, Webster MEG. The English hospital 1070-1570. New Haven: Yale University Press; 1995
[3] McKenny GP. To relieve the human condition : bioethics, technology, and the body. Albany, N.Y.: State University of New York Press; 1997.
[4] Risse GB. Hospital life in enlightenment Scotland : care and teaching at the Royal Infirmary of Edinburgh. Cambridge Cambridgeshire ; New York: Cambridge University Press; 1986.
[5] Abel EK. “In the last stages of irremediable disease”: American hospitals and dying patients before World War II. Bulletin of the history of medicine. 2011;85(1):29-56.
[6] Becker E. The denial of death. New York,: Free Press; 1973.
[7] Fulop M. The teaching hospital’s modern deathbed ritual. The New England journal of medicine. 1985;312(2):125-126.