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Why are Medicine and Religion Separate? Part 1: The Evolution of the Hospital
Tuesday February 27th 2018, 8:45 pm
Filed under: history of medicine and religion,hospitals,palliative care

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.

[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.

Modernity implies complexity. More knowledge spawns more concepts, specialties, sub-specialties, lab tests, etc., against our fixed power to comprehend.

Like the article states, the religious values of the first hospitals (from “spittle house” from pneumonia, etc.), have been displaced by the pragmatic values of additional regulators (cultural, legal, pecuniary, academic).

This displaced the person-centered religious view (each person is a child of God), to the accounting view of patients and doctors as fungible units.

Brigham and Women’s Hospital initially treated many patients all together in one large room. A curtain could be drawn to give each patient privacy, or retracted to let them watch the continual live show — here come the dinner carts, the nurses and aides to bath us and make our beds, the doctors on rounds, etc. This tended to orient otherwise disoriented patients. The development of different values outlawed this option.

Hence, many newer forces, e.g., medical, legal, monetary, egalitarian, ethical, effected the current complexity in architecture and health care.

Comment by Quentin Regestein 02.28.18 @ 8:39 pm

Thanks Reg. All good points.

Comment by healthreligionspirituality 03.01.18 @ 8:53 pm

Interesting info about medieval Islamic Hospitals (Bimaristan) from NIH

The hospital was one of the great achievements of medieval Islamic society. The relation of the design and development of Islamic hospitals to the earlier and contemporaneous poor and sick relief facilities offered by some Christian monasteries has not been fully delineated. Clearly, however, the medieval Islamic hospital was a more elaborate institution with a wider range of functions.

In Islam there was generally a moral imperative to treat all the ill regardless of their financial status. The hospitals were largely secular institutions, many of them open to all, male and female, civilian and military, adult and child, rich and poor, Muslims and non-Muslims. They tended to be large, urban structures.

The Islamic hospital served several purposes: a center of medical treatment, a convalescent home for those recovering from illness or accidents, an insane asylum, and a retirement home giving basic maintenance needs for the aged and infirm who lacked a family to care for them. It is unlikely that any truly wealthy person would have gone to a hospital for any purpose, unless they were taken ill while traveling far from home. Except under unusual circumstances, all the medical needs of the wealthy and powerful would have been administered in the home or through outpatient clinics dispensing drugs. Though Jewish and Christian doctors working in hospitals were not uncommon, we do not know what proportion of the patients would have been non-Muslim.

An Islamic hospital was called a bimaristan, often contracted to maristan, from the Persian word bimar, `ill person’, and stan, `place.’ Some accounts associate the name of the early Umayyad caliph al-Walid I, who ruled from 705 to 715 (86-96 H), with the founding of a hospice, possibly a leprosarium, in Damascus. Other versions, however, suggest that he only arranged for guides to be supplied to the blind, servants to the crippled, and monetary assistance to lepers.

The earliest documented hospital established by an Islamic ruler was built in the 9th century in Baghdad probably by the vizier to the caliph Harun al-Rashid. Few details are known of this foundation. There is no evidence to associate the construction of the earliest hospital with any of the Christian physicians from Gondeshapur in southwest Iran, but the prominence of the Bakhtishu` family as court physicians would suggest that they also played an important role in the function of the first hospital in Baghdad.

In little more than a hundred years, 5 additional bimaristans had been built in Baghdad. According to some accounts, directions were given by a vizier in the early 10th century to provide medical care to prisons on a daily basis and visits by doctors with a traveling dispensary to villages in lower Iraq. The most important of the Baghdad hospitals was that established in 982 (372 H) by the ruler `Adud al-Dawlah. When it was founded it had 25 doctors, including oculists, surgeons, and bonesetters. In 1184 (580 H) a traveller described it as being like an enormous palace in size.

Comment by Katrina Scott 03.01.18 @ 8:06 pm

Thanks Katrina. Nice summary. Gary Ferngren has a good chapter in his book, “Medicine and Religion” that captures some of the Islamic shaping of medicine, and I also recommend Rahman’s “Health and Medicine in the Islamic Tradition” published in 1987. Harvard Divinity’s Ahmad Ragab also has a good book on the topic, “The Medieval Islamic Hospital” published with Cambridge U Press in 2015. All great resources for the interested reader.

Comment by healthreligionspirituality 03.01.18 @ 8:58 pm

Nice article, I really enjoyed it. I need to document this.. At least I have a wide knowledge why medicine and Religion are distinct

Comment by clara Weldon 03.09.18 @ 9:46 pm

The question needs to be asked in different population. Medicine should not be separated from religion, thanks to the growing concern now. Spirituality in healthcare is budding.

Comment by Omololu Fagunwa 04.24.18 @ 10:52 am