1

Title:

Development of the Connection Between Spirituality and Medicine:

Historical and Current Issues in Clinics1

ABSTRACT:

The incorporation of spirituality into Western clinical culture is quite

recent. In fact, it began scarcely four decades ago. In spite of its

recent institutionalization, this phenomenon cannot be understood to

its fullest extent without examining the conditions that made it

possible. Some are ancient, others are recent. My aim is first to

identify and explore some of these conditions, internal as well as

external to the biomedical realm, that can be linked to this

phenomenon, and secondly, to discuss some crucial issues for the

praxis of spiritual care.

INTRODUCTION

The openness of clinical culture and Western health institutions to

spirituality in times of illness is a relatively recent phenomenon. It

began no more than forty years ago. Of course, the Western world has

a long-standing hospital tradition whereby institutions and

establishments have been directly or indirectly influenced by 1 This text was first delivered as a presentation on March 10, 2016 at the Colloque du Carrefour spirituel des Cliniques Universitaires Saint-Luc [Conference of the Spiritual Service of Saint Luc University Clinics], Brussels, Belgium.

2

Christian religious traditions. However, this coexistence that dates

back to Christianity in late Ancient Roman times (Conrad et al. 1995)

with the establishment of hospices to care for poor and isolated sick

people, has always respected the boundaries between medical and

religious practices. In more direct terms, priests did not meddle with

medical care and doctors were not perceived as spiritual caregivers.

This clear separation no longer stands, at least with respect to the

biomedical interest in spiritual matters.

The change in relationship between medicine and spirituality is due to

profound transformations in the Western world’s relationship with

religion, as well as the changes in the clinical culture, particularly due

to the rapid techno-scientific development of contemporary

biomedicine. Yet this openness also raises major issues in terms of

caregiving for patients and their loved ones. To better understand the

current clinical issues raised due to the biomedical interest in

spirituality, it would be useful to identify some key moments in history

that brought it about. I will start by retracing certain key stages in the

institutionalization of spiritual acceptance in Western clinical culture,

then identify the issues raised by this acceptance for discussion

purposes.

1. SOME KEY STAGES LEADING TO THE INSTITUTIONALIZATION OF SPIRITUAL

ACCEPTANCE IN WESTERN CLINICAL CULTURE

3

When the modern clinic becomes a place where the focus is on the

forces that determine the acceptance of the spiritual experience, one

might think at first glance that this is a break with a long-standing

tradition. In my view, this opinion should be revised to reflect that the

phenomenon is, in fact, part of a long history. One cannot understand

the current phenomenon without looking at the historic connections

between Western medicine and religion. The ups and downs of the

relationship had and continue to have an influence up close and from

afar on the processes for integrating spirituality into the institutional

arrangements and clinical practices of health care establishments.

Historic and recent events can be divided into two categories: those

inherent in the medical world and those pertaining to contemporary

culture.

1.1 Stages in the biomedical world2

The events presented and discussed here clarify the stages in the long

process of divergence and convergence of care and questions about

meaning inherent in religious and spiritual traditions.

1.1.1 Secularization and rationalization of medicine

In my view, to understand the current convergence of medicine and

spirituality, you need to go back to the time when religion and

medicine were separated. That means going back to the 5th century

2 The term “biomedical world” should be understood in a broader context that includes all heath care professions, especially nursing, which work alongside the medical profession.

4

BC and examining the work of the medical movement claiming to be

followers of Hippocrates of Cos. The main contribution of this

founding movement of Western medicine, aside from the famous Oath

that defined medical ethics until the 1960s, was to take a more

practical approach to the causes of illness and their cures. Contrary to

their predecessors, Hippocratic physicians did not consider

themselves intermediaries between the divinities and the patient.

They were no longer the advocates whose role was to curry the favour

of the gods to ensure good health or deflect their divine wrath to

prevent illness. In this unprecedented position, physicians began to

play an active role in restoring the body’s balance, which guarantees

good health for everyone. In this medical tradition, human beings are

healthy when the four humours (bodily fluids) they are made of are

well balanced: blood, phlegm, yellow bile and black bile (Conrad et al.

1995). According to Hippocratic corpus specialist Jackie Pigeaud

(Pigeaud 2009), ‘separating the sickness from the religious curse

gives dignity to both the patient and physician by removing the

responsibility from the patient and adding one for the physician.” The

art of the physician is practised by taking direct action on the body

through food, exercise or pharmacopeia. In so doing, religious

intervention and rituals are no longer tied to the act of care. By

associating health and sickness with causes internal to the human

body, Hippocratic medicine laid the groundwork for the connections

5

that followed between medicine and religion in the Western clinical

culture, which was characterized by a relationship of non-interference

between the two fields. Although a connection remained between

religion and medicine, it was limited to the professional identity,

moral framework of medical practice – which is emphasized in the

invocation of the gods in the Hippocratic Oath – and to the sources of

the motivation for taking care of others. For example, religious values

were historically a source of the commitment to medical practice and,

more generally, health care practices. In this respect, the Gospel

According to Matthew 25, 36 played a key role in justifying Christians’

commitment to care practices, whether or not the latter are

professional.

1.1.2 Practical empowerment of spiritual caregiving in times of illness

Let’s take a great leap forward in history to the 1920s when the

Clinical Pastoral Education (CPE) movement emerged. Led by

American Protestant chaplain Anton Boisen, the movement changed

spiritual caregiving in the Protestant world. It promoted clinical

pastoral education in the field and was no longer solely based on the

theological knowledge acquired in seminaries for educating clerics. In

the autobiographical-style introduction of his book The Exploration of

the Inner World, Boisen affirms his belief that the spiritual experience

in times of illness – in this case, it was a form of mental illness – can

be well identified and cared for through the fields of theology and

6

psychiatry (Boisen 1962(1936)). The CPE experience provided the

basis for the demands that later led to the institutionalization of a type

of spiritual caregiving specific to health care settings. It launched the

movement that led to the independence of hospital chaplaincy as

compared to pastoral or social ministry. The movement first emerged

in Protestant circles, then spread to Catholic ones. In Quebec, for

example, Catholic chaplains in hospitals sought special status and

recognition, distinct from for the pastoral structures of dioceses in the

early 1970s.

1.1.3 Nursing interpretation of the spiritual experience

Let’s move forward to the 1950s, again in the United States, which is

when American nurse Virginia Henderson developed her theory of

nursing care as a response to the “fundamental needs of all patients.”

(Henderson 1960) Basic nursing care includes helping patients by

ensuring they can practice their religion. Henderson explained that

this kind of care is an act that respects “patients’ rights to uphold

their religious beliefs during their hospital stay. […] Respecting

patients’ spiritual needs and ensuring that they can meet them under

any circumstances is part of basic nursing care.” (Henderson 1960 p.

51) To my knowledge, this is the first time that the term “spiritual

need” was used in nursing care, even if the religious meaning that

Henderson gives it is different from the humanist meaning that

current theorists give to the term. Unless I am mistaken, it was the

7

first time in the modern era that a health care profession integrated

the religious or spiritual issue as a goal in its practice.

1.1.4 Critical discourse outside the medical world

Two major events in the 1960s had a strong impact on the subject.

First of all, there was the institutionalization of bioethics in the 1970s

when oncologist Van Rensselaer Potter and philosopher André

Hellegers proposed the term “bioethics” independently of one another

to respectively designate the area where biological sciences enter into

dialogue with ethics, along with the emerging discipline of ethics in

health care. Theologians like Paul Ramsey (Ramsey 1970), Bernard

Häring (Häring 1973), James Childress (Beauchamp and Childress

2012) or philosophers with an interest in theology (Pellegrino,

Langan, and Harvey 1989; Pellegrino and Thomasma 1988) entered

clinical settings and worked to incorporate the bioethics discipline

and practices into the culture of health care establishments. The

advent of bioethics generated interest in secular reflection – which

ironically was initially raised by Christian theologians – on the ethical

issues that arose with the introduction of technosciences into care

and the ethical issues inherent in biomedical research on human

subjects. Without it being a “return to religion” in the biomedical

world, the advent of bioethics and its institutionalization were a major

milestone in the introduction of biomedicine to the “disciplines of

meaning”, such as philosophy and theology. The arrival of theologians

8

in the medical world does not, however, imply a fundamental opening

of the medical field to spirituality; far from it! Nevertheless, it’s an

additional stage in the history of the convergence described here. The

upshot of this convergence was that the biomedical world had to

address issues of finiteness, vulnerability and meaning – matters

associated with spirituality by the 1990s.

1.1.5 Institutionalization of palliative care

The second event – one that is central to my topic – is, of course, the

establishment and institutionalization of palliative care. Cicely

Saunders’ brilliant insight into “total pain” and and its care created

two breaches in the biomedical thinking of his time. The first breach

was created by the establishment of an end-of-life care system where

there is still something to be done when curative treatment is no

longer suitable (Jacquemin 2004). The comfort care associated with

the palliative movement include caregiving practices reminiscent of

ars moriendi and preparation for death as it was perceived just before

the Renaissance (Bayard 1999). Work by Canadian psychiatrist

Harvey M. Chochinov, particularly his dignity therapy program,

illustrates the establishment of a formalized holistic caregiving step in

end-of-life care (Chochinov 2005; Chochinov 2006, 2008; Chochinov et

al. 2011). There is a parallel to be drawn between this contemporary

research and ars moriendi (Cherblanc and Jobin 2013).

9

The second breach came with the introduction of a health care

philosophy that builds caregiver awareness of the overall illness

experience. A broader view of end-of-life illness will incite the

caregiving team to be more attentive to the repercussions of

approaching death on patients’ spiritual experience. The latter

becomes a care concern when issues of meaning arise with the patient

who is moving inexorably toward death. At least, that is how it is

portrayed in palliative care literature.

1.1.6 A change in the clinical view

Lastly, the medical view itself is broadening beyond the biology and

physiology of disease. In 1977, psychiatrist George Engel published

an article in the prestigious journal Science calling for a new medical

model that would amalgamate psychological and social repercussions

with strictly biological repercussions of illness (Engel 1977). In

retrospect, we clearly can say that the article and clinical practices he

made possible acted as a catalyst by tying together the various

elements that now comprise the conditions that made convergence

possible between biomedicine and meaning-related issues brought to

the fore by religious and spiritual traditions.

* * *

The combined effect of these historic milestones led to the proposed

biopsychosocial and spiritual model of patient care. This model, which

10

is the work of Franciscan Daniel P. Sulmasy, an American Catholic

physician and theologian, is based on a normative understanding of

the human beings characterized by the relationship among the

various “elements” of which humans are made: the body (where the

organs are in a physiological relationship with one another), the mind

in relation to the body and, lastly, the relationships between

individuals and what is external to them: physical environment, social

world and transcendence, in whatever form it takes for the patient

(Sulmasy 2002). Again, according to Sulmasy, by adopting this four-

part patient care model, modern medicine will leave behind the

modern clinic that Foucault described so well in The Birth of the

Clinic, and revive the deep intuitions of the long-standing Western

medical tradition that make this particular form of care, and care in

general for that matter, a fundamentally spiritual experience (Sulmasy

2002).  Sulmasy’s proposal is a patent example of the development of

biomedical thinking on the spiritual experience in times of illness

(Sulmasy 2007). The example is even more evident when associated

with the steady growth in biomedical publications on the importance

of the attention to be paid to the spiritual experience and its clinical

management.

1.2 Stages in contemporary culture

Medical settings are not isolated from societies and cultures; they are

connected to them. This explains why the new-found medical concern

11

for the spiritual experience in times of illness cannot be understood

without looking at the transformations in the connection between

spirituality and religion in Western societies. I will highlight three

factors that I find important.

1.2.1 Ethno-religious pluralization

First, there is the ethno-religious pluralization of Western societies.

The religious profile of the West has changed considerably since the

middle of the 20th century for various reasons that I won’t list here.

What’s important to remember is that ethno-religious plurality forced

the health care field to acknowledge an important reality, which was

that institutions had to adapt to the new situation. They could no

longer rely on the reflexes learned in a context where Christianity had

a virtual monopoly status.

For example, in places where spiritual caregiving for patients is

considered part of a health care establishment’s mission, interfaith

spiritual care services were introduced, or secular services – as in

Quebec – in response to the socio-religious and spiritual

transformations in pluralistic societies.

1.2.2 Secularization of institutions

In what appears to be an irony of history, ethno-religious pluralization

began at a time when Western culture was becoming secular and, as

in Quebec, so were health care institutions. They became secular and

12

divested themselves of religion-based governance. It should be noted

that the secularization of health care establishments is a phenomenon

that inevitably takes on a political dimension. In fact, the acceptance

of spirituality in an institution will be influenced by the type of

secularity that governs the political control of religion in a particular

State. For instance, Quebec’s healthcare institutions have a legal duty

to answer the spiritual needs of their patients ("Loi sur les services de

santé et les services sociaux [Act respecting health services and social

services]" 2005). On the other hand, in France, a state healthcare

institution cannot establish, on its own, a spiritual care service

(Caudullo, Mathiot, and Sarradon-Eck 2016). Therefore, there will be

various approaches to the acceptance of spirituality in institutions;

one model will dominate based on the State’s political control over

religion.

1.2.3 Connections between spirituality and religions

The connection between different forms of spirituality and religious

traditions has been changing since the middle of the 20th century in

pluralistic societies. Recent works on the sociology of spirituality

clearly show the dissociation, in contemporaries’ descriptions, of

spiritual life and religious traditions (Heelas 2008; Heelas and

Woodhead 2005; Liogier 2012; Stolz et al. 2015). Spirituality is

perceived as a more widespread phenomenon that is more all-

encompassing than religion. The key feature of this fairly common

13

way of seeing and thinking – dare I say “feeling” – about spiritual life

is to link it directly to human nature, whereas the religious expression

of spirituality is perceived as a cultural phenomenon. Spirituality then

takes on a permanent and all-encompassing feature – through its

association with the very nature of humans – in the face of the historic

relativity of religious traditions. This presentation describes

spirituality as a reality independent of religious traditions, in fact, of

any tradition at all. Spiritual life becomes the place where the

uniqueness of every individual is anchored and expressed. Spirituality

thereby acquires a status similar to that of the conscience.

* * *

The historical development outlined here was caused by events

internal and external to the biomedical world. In their own way, these

events affected the current acceptance of spirituality in terms of the

institutional arrangements and clinical practices in response to the

spiritual experience in times of illness. The convergence of

biomedicine, spirituality and religions due to these historical and

recent events raises crucial issues and challenges described below.

2. ISSUES RAISED BY THE ACCEPTANCE OF SPIRITUALITY IN THE HEALTH CARE

FIELD

I have identified four groups of issues that the transformations

described here raise. They are issues that form a system. The issues

14

are interrelated and linked. The order in which the issues are

presented does not imply any priority or causal relationship among

them.

2.1 The function of spirituality issue

The pragmatic nature of the biomedical integration of spirituality is

called into question. What does spirituality contribute to the clinical

world? For what purpose(s) are we bringing spirituality into play? Do

we perceive it as an accessory to care that could compensate for the

coldness of clinical practices that are becoming increasingly

technical? Or is it an adjuvant to recovery or adaptation processes for

the conditions imposed by the illness on patients and their loved ones?

From an institutional standpoint, is it a factor in the humanization of

institutions and the health care relations tied to them? Underlying

these questions, the very status of spirituality in techno-scientific

culture is called into question: Will spirituality be another item on

which the biomedical field will exert its power? We need only look at

how the biological sciences and biomedical technoscience have jointly

changed the reality and the definition of notions such as life, death,

health and illness. Finally, will the preoccupation with the spiritual

experience make way for thought and action aimed at transforming

health care institutions?

2.2 The interpretation of spiritual experience issue

15

Questions related to the pragmatic status of spirituality in a clinical

setting also open up a whole other line of questioning regarding the

categories of interpretation of spiritual experience. Clearly, it is no

longer understood using the categories stemming from Western

religious traditions. Rather, it will be in the epistemological and

clinical categories, respectively thought and action categories, of

biomedicine and health care management that spiritual experiences

will be named and evaluated.

Along the same lines, the optimal spiritual experience is understood

as the ability to experience well-being, but also as the individual

ability to give or bestow meaning upon the events experienced. In

times of illness, the optimal experience may manifest itself as

serenity, inner peace, acceptance, etc. The absence of spiritual well-

being will be perceived as a spiritual need - the reader will see that

the concept of spiritual need here is different from the one proposed

by V. Henderson. It can also be perceived as spiritual distress. i.e “the

impaired ability to experience and integrate meaning and purpose in

life through a person’s connectedness with self, others, art, music,

literature, nature, or a power greater than oneself” (Sessanna, Finnel,

and Jezewski 2007), depending on the severity of the symptoms

observed. The reader can readily see the healthy/sick dichotomy here,

which is fundamental to medical thought, applied to the spiritual state

of a patient. We can rightly question ourselves if these categories

16

would sufficiently encompass the wide range of spiritual experiences

likely to be faced in times of illness, some of which may seem atypical

in the eyes of caregivers. I am thinking of someone in the early stages

of palliative care who refuses to take analgesics, with full knowledge

of the facts, in order to merge his pain and suffering with that of

Christ on the cross. This spiritual experience, which is considered a

legitimate one in Christianity, goes against the palliative care

philosophy on both comfort and caregiving practices.

It therefore seems necessary to alert caregivers to the great

variability in spiritual experiences and the need for extreme caution

when asked to “assess” the spiritual state of a patient. It’s also worth

repeating the fact that a spiritual experience is not something to be

treated, but rather an opportunity for spiritual caregiving. This

nuance is crucial to prevent the “medicalization” of atypical spiritual

states from a clinical culture viewpoint.

2.3 The language issue

The previous issue covered raises a related question about language

and the categories used to describe spiritual life. Clinical language

does not refer to religious traditions to understand and name spiritual

experiences in times of illness. In fact, a whole language set specific

to the biomedical field was developed to name and discuss this aspect

of the illness experience. The issue raised by the creation of this

clinical language is how it interfaces with the language(s) that

17

patients use to describe their own spiritual experience. As in the

example given in the previous note, it’s possible that the languages

don’t interface, so the caregivers and patients do not understand each

other. Some categories of patients simply may not understand the

clinical language of spirituality (particularly elderly people or those

who adhere to a religious tradition). The opposite is also true. It is not

unreasonable to think that young caregivers who are increasingly less

familiar with religion may be confused by certain spiritual

experiences. In short, one needs to be aware that the clinical

language for spirituality is only one language among many, including

the spiritual religious traditions. This raises a translation issue from

one “spiritual language” to another, which I find crucial. The

ethnoreligious plurality of Western societies demands it. Yet it seems

to me that well trained spiritual caregivers can play a leading role as

spiritual language translators.

2.4 The spiritual caregiving training in health care settings issue

In the Western world, there is a strong trend toward the

“professionalization” of spiritual caregiving in health care settings.

This includes adopting a position whereby spiritual caregivers are

institutional stakeholders who can justify decisions made and actions

taken as part of their job. The “professionalizing” option for spiritual

caregivers in their initial and continuous education also assumes that

they base themselves on a corpus of theories, texts and actions

18

validated by the clinical practice community. The fact that in a

number of western countries, training is acquired in a postgraduate

practical path contributes to the image of concrete expertise

underlying the position adopted by spiritual caregivers. If the

intuitions of A. Boisen and the CPE movement led to the

empowerment of spiritual caregiving in health care settings in

relation to the traditional theological and ecclesiastical authorities,

the “professionalization” took over and oriented the option in this new

direction. For reasons related to both the accountability of clinical

actions – the ethical side of professional responsibility – and the

credibility imperative for spiritual caregiving in a highly specialized

environment like health care institutions, training for spiritual

caregivers will be based on theoretical knowledge and solid practices

adapted to clinical settings.

The “professionalizing” orientation of spiritual caregiving raises a

related issue: the role of volunteers and medical staff in spiritual

caregiving for patients and their loved ones. While recognizing that

these are two different situations, it is a shared issue, because it

raises the question about the skills required for spiritual caregiving

once spiritual caregivers are integrated into the organizational chart

of a health care institution. The training issue also raises the question

of action: who will provide spiritual caregiving? The issues are

presented here in a general manner. However, the political and

19

institutional decisions specific to each health care system and each

state will have a significant influence on the form and scope of these

issues. Yet these issues are fundamental at this point – in the sense

that they will extend beyond states’ borders and national health care

systems. A proper assessment should include reflection that is

sensitive to the ancient and modern developments that have marked

the history of Western medicine.

CONCLUSION

The excitement surrounding contemporary research on spirituality

and health, combined with the renewal of spiritual caregiving

practices in times of illness, can easily overshadow the fact that this

field was only able to emerge with the combination of certain

favourable conditions. Identifying a few of these conditions for the

possibility of incorporating spirituality into Western clinical culture

and discussing the issues raised is not aimed at making history a

destiny, but rather to place this recent phenomenon in a larger and

longer-term picture.

Bayard, Florence. 1999. L'art de bien mourir au XVe siècle [The Art of Dying Well in the 15th Century] (Presses de l'Université de Paris-Sorbonne: Paris).

Beauchamp, Tom L., and James F. Childress. 2012. Principles of Biomedical Ethics (Oxford University Press: Oxford).

20

Boisen, Anton T. 1962(1936). The Exploration of the Inner World. A Study of Mental Disorder and Religious Experience (Harper & Brothers: New York).

Caudullo, Coralie, Aurélia Mathiot, and Aline Sarradon-Eck. 2016. 'De la difficulté à faire exister une unité de soins spirituels dans un hôpital universitaire français [The difficulty of maintaining a spiritual caregiving unit in a French teaching hospital]', Sciences sociales et santé, 34: 5-28.

Cherblanc, Jacques, and Guy Jobin. 2013. 'Vers une psychologisation du religieux ?. Le cas des institutions sanitaires au Québec [Toward the Psychologizing of Religion? The Case of Quebec Health Care Institutions]', Archives de sciences sociales des religions, 163: 39-62.

Chochinov, H. M., L. J. Kristjanson, W. Breitbart, S. McClement, T. F. Hack, T. Hassard, and M. Harlos. 2011. 'Effect of dignity therapy on distress and end-of-life experience in terminally ill patients: a randomised controlled trial', Lancet Oncol, 12: 753-62.

Chochinov, Harvey M. 2006. 'Dying, Dignity, and New Horizons in Palliative End-of-Life Care', CA. A Cancer Journal for the Clinicians, 56: 84-103.

———. 2008. 'Dignity-Based Approaches in the Care of Terminally Ill Patients', Curr Opin Support Palliat Care, 2: 49-53.

Chochinov, Harvey Max. 2005. 'Dignity Therapy : A Novel Psychotherapeutic Intervention for Patients near the End of Life', Journal of Clinical Oncololy, 23: 5520-25.

Conrad, Laurence I., Michael Neve, Vivian Nutton, Roy Porter, and Andrew Wear. 1995. The Western Medical Tradition, 800 BC ot AD 1800 (Cambridge University Press: Cambridge).

Engel, George L. 1977. 'The need for a new medical model: a challenge for biomedicine', Science, 196: 129-36.

Häring, Bernard. 1973. Medical Ethics (Fides: Notre Dame, Ind.).Heelas, Paul. 2008. Spiritualities of Life. New Age Romanticism and

Consumptive Capitalism (Blackwell: Oxford).Heelas, Paul, and Linda Woodhead. 2005. The spiritual revolution :

why religion is giving way to spirituality (Blackwell Pub: Malden, MA).

Henderson, Virginia. 1960. Basic Principles of Nursing (International Council of Nurses: Geneva).

Jacquemin, Dominique. 2004. Éthique des soins palliatifs [Ethics of Palliative Care] (Dunod: Paris).

Liogier, Raphaël. 2012. Souci de soi, conscience du monde : vers une religion globale? [Concern for Oneself, Concern for the World. Toward a Global Religion?] (Armand Colin: Paris).

"Loi sur les services de santé et les services sociaux [Act respecting health services and social services]." In. 2005. S-4.2, edited by

21

de la santé et des services sociaux Ministère. Québec: Gouvernement du Québec.

Pellegrino, Edmund D., John Langan, and John Collins Harvey. 1989. Catholic perspectives on medical morals : foundational issues (Kluwer Academic Publishers: Dordrecht).

Pellegrino, Edmund D., and David C. Thomasma. 1988. For the patient's good : the restoration of beneficence in health care (Oxford University Press: New York).

Pigeaud, Jackie. 2009. Poétiques du corps. Aux origines de la médecine [Poetics of the body. At the Origins of Medicine] (Les Belles Lettres: Paris).

Ramsey, Paul. 1970. The Patien as Person (Yale University Press: New Haven).

Sessanna, L., D. Finnel, and M. A. Jezewski. 2007. 'Spirituality in Nursing and Health-Related Literature. A Concept Analysis', Journal of Holistic Nursing, 25: 252-62.

Stolz, Jörg, Judith Könemann, Mallory Schneuwly Purdie, Thomas Englberger, and Michael Krüggeler. 2015. Religion et spiritualité à l'ère de l'ego : profils de l'institutionnel, de l'alternatif, du distancié et du séculier [Religion and spirituality in the era of the ego. Institutional, alternative, distancing and secular profiles] (Labor et Fides: Genève).

Sulmasy, D. 2007. The Rebirth of the Clinic. An Introduction to Spirituality in Health Care (Georgetown University Press: Washington, D.C.).

Sulmasy, D. P. 2002. 'A biopsychosocial-spiritual model for the care of patients at the end of life', Gerontologist, 42 Spec No 3: 24-33.