J Am Board Fam Med: first published as 10.3122/jabfm.2010.06.100064 on 5 November 2010. Downloaded from

REFLECTIONS IN FAMILY MEDICINE Is There a Shaman in the House?

Peter de Schweinitz, MD, MSPH

This nonfictional narrative recounts a story of shared decision making between a veteran neurosurgeon and the family of a comatose patient who had suffered a hemorrhagic stroke. After reviewing the option of surgery within the context of informed consent, the family remains frozen in indecision. Leaving be- hind him the world of the rational, the neurosurgeon makes a statement that reconnects the family to their deepest values. The neurosurgeon is portrayed as a modern equivalent of a shaman. A call is made for consideration of the complex topic of spiritual engagement during patient care. (J Am Board Fam Med 2010;23:794–796.)

Keywords: Communication, Decision Making, End-of-Life Care, Doctor-Patient Relations, Spirituality

Every 6 weeks my 80-year-old colleague sits down Driving home, I remembered an unusual healer with third-year medical students for approximately I’d met 10 years earlier when I was a second-year an hour and a half and shares some wisdom from resident in a suburban emergency department. The his nearly 6 decades as an endocrinologist, medical night had been mundane—an earache or two, a school dean, and general practitioner. My colleague laceration, an admission for pneumonia—when a has a deep respect for scientific medicine. None- nurse approached. “Wanna see someone?” I noted copyright. theless, he likes to tie students into a tradition that the chief complaint and stepped into the room to began long before the invention of the scientific find an elderly couple. Mrs. Dorsett had permed method. “Before there was science,” he says, “there brown hair and a face taut with unexpressed fear. was the shaman.” Perhaps demonstrating one Mr. Dorsett lay absolutely still, his robust feet pro- truding beyond the limits of the sheet. Not even a method of healing to the students, he places a sternal rub would arouse him. The radiologist’s warm, wrinkled hand on my shoulder. “The sha- reading of the computerized axial tomography scan man had none of the pharmaceuticals or procedural was superfluous. Even for a novice like me, the skills that we associate with modern medicine, but

pathology was obvious. http://www.jabfm.org/ he had something.” After speaking of the impor- By the time the on-call neurosurgeon arrived, a tance of compassion for human suffering, my col- crowd of nervous sons, daughters, and spouses had league ends his story by suggesting that human assembled. With his sharp white coat and tie, Dr. beings have evolved with shamanism and therefore Walker was the image of a medical professional. have come to depend on its healing comforts. After a brief introduction, he turned to the white-lit “What right do we have—just because we have radiograph box on the wall, dispassionately re- science—to deny patients what they have enjoyed viewed the images, and turned to address the fam- on 30 September 2021 by guest. Protected for millennia?” ily. “Mr. Dorsett has had a stroke,” he announced. “It’s a large one, a large bleed into what we call the cerebellum.” Although I’d already made a similar This article was externally peer reviewed. announcement, from Walker the words had more Submitted 16 March 2010; revised 10 June 2010; accepted gravity. 21 June 2010. From the Department of Family and Preventive Medi- “What do we do?“ a son asked. No advance cine, University of Utah, Salt Lake City. directive was available. Funding: none. Conflict of interest: none declared. Walker explained the possibility of a procedure Corresponding author: Peter de Schweinitz, MD, MSPH, and its risks in clear, lay language: the process of Department of Family and Preventive Medicine, University of Utah, 375 Chipeta Way, Suite A, Salt Lake City, UT anesthesia, the opening up of a “window,” the dis- 84108 (E-mail: [email protected]). section of the blood clot. The couples asked ques-

794 JABFM November–December 2010 Vol. 23 No. 6 http://www.jabfm.org J Am Board Fam Med: first published as 10.3122/jabfm.2010.06.100064 on 5 November 2010. Downloaded from tions about the neurosurgeon’s experience, recov- at the door. Even with my insider’s knowledge of ery times, and postoperative rehabilitation. “We physician culture, I could not tell whether he can try to remove the blood clot,” he said. “But, we wanted to cut. have to accept the very real possibility that he As a last ditch effort, an older daughter directly might not survive surgery.” addressed Mrs. Dorsett, who had not yet spoken. For a moment the family was quiet. “What do you think we should do, Mom?” One son wanted exact statistics. “What are the Mrs. Dorsett looked down at her husband. He chances of him dying during the operation?” lay still as ever. She looked up at Walker, who Walker rubbed his chin. “To be completely returned her gaze with solemn dignity, but no di- honest, that is a very difficult question to answer. If rection. I had to make my best guess, I’d say there is at least “I don’t know.” a 50–50 chance that he would not make it Whereas the typical physician seeks answers in through.” the empirical domain, the shaman travels to an A daughter wanted more precise odds regard- invisible realm. Walker had reviewed a computed ing postoperative function. Although not without axial tomography scan, checked pupils with a pen- hope, Walker was gravely realistic. “Even if he light, and tapped on a few tendons. He’d calculated survives, there is a good chance that he will suffer statistical probabilities and rationally considered from significant problems with basic daily func- the options. Now he turned his eyes to the floor. tions like eating, walking, and bathing.” For the For a couple of seconds he seemed lost in the next several minutes Walker answered questions white linoleum, immersed in a separate dimen- as the family processed the information in a ra- sion. I don’t know if this dimension is best de- tional and objective manner, chewing on the risks scribed in spiritual or poetic terms, as a “higher and benefits of proceeding to the operating sphere”; in psychological terms, as a “mental room. mode”; or in neuroanatomical terms, as a “par- Despite their health literacy and capacity to rea- allel neuronal circuit.” Regardless, when he copyright. son, however, the path forward remained unclear. looked up, he seemed to be wearing a different Intensive discussion trailed off into a silence pene- mantle. Directing his words to no one in partic- trated only by the type of in-breath one makes just ular, his voice flowed with subtle melody. before speaking. On the edge of anxiety, each fam- “No one knows when his Savior will come to ily member looked to each other, as if that other bring him home,” he said. might possess the missing fact or insight, or at least All of a sudden faces relaxed into tears. I felt the resolve to make a decision—surgery or no. opened from the inside.

Even Walker’s question, “What would your father A few seconds passed and the older daughter http://www.jabfm.org/ want for himself?” was met with uncertainty. broke the silence: “Dad has lived a good life.” As physicians, we render a clear synopsis of the When Dr. Walker and I left the room a few min- medical facts. We seek to understand the values and utes later, the family was unanimously resolved to preferences of the patient. We express respectful and at peace with the impending death of their support for the autonomy of the family. But what beloved. happens when, despite our best efforts at education There are many physicians and patients who and explanation, the family cannot make a deci- aspire to the emotional and spiritual engagement on 30 September 2021 by guest. Protected sion? Many families do not want us to stay neutral. exemplified by Walker’s interaction with the They find ways to work around our neutrality. Dorsett family. Yet there are many who might They say, “What would you do if this were your also recoil at his use of religious terminology, wife/husband/father?” Perhaps we’re quite aware especially before explicit inquiry into the belief that our words may deeply influence the trajectory system of the patient and family. And with good of many lives. Some of us may feel comfortable reason. In a diverse world, both physicians and accepting this responsibility. Others may not. patients are and should be wary of easy assumptions The family didn’t ask this question. Even if they and uses of religion in public or even private had, I doubt Walker would have answered squarely. spheres. Should medical educators introduce and Walker had mastered the modern art of informed explore more than medical technology, more than consent, leaving personal preferences, even values, rational ethical concepts? Certainly we don’t need doi: 10.3122/jabfm.2010.06.100064 Is There a Shaman in the House? 795 J Am Board Fam Med: first published as 10.3122/jabfm.2010.06.100064 on 5 November 2010. Downloaded from more charlatans, be they overexuberant oncologists visceral and authentic relationship with their fa- or mystical herbalists. Should we physicians, as my ther. Although we rightly focus on the dangers of octogenarian colleague suggests, carry on the tra- imposing our values on vulnerable patients, it dition of shamanism despite our science? What can would be intellectually irresponsible to dismiss we learn by looking past stereotyped images of the the power of Walker’s intervention simply be- shaman: the rattles and drums, the mashed up or- cause he invoked religion. ganic materials and mystical visions? How do we proceed, then, not only in cases of The shaman serves as a bridge between ordinary dying, but at the varied intersections of meaning and extraordinary human consciousness. He or she and health? Must we rely solely on the rational steps out of ordinary thought into the world behind concepts of modern bioethics or is there a primor- the visible, what depth psychologists may under- dial language of the soul—a shamanistic inheri- stand as the subconscious or mythological realm. In tance common to human beings—that has survived service to humanity, the shaman evokes a ritual the diverse evolutions of culture and religion? If space of healing and transformation that circum- not, is it deceptive and unethical to adopt the pa- vents the usual rational mental structures that have tient’s metaphorical world when it runs counter to blocked healing or growth. But although the sha- the beliefs and values of our own? Or can the man can be found in most, and perhaps all, societies physician, chameleon-like, safely use a patient’s throughout the world (universal), his or her meth- foreign terminology as a form of trained cultural ods, cosmologies, and treatments are highly con- and narrative competence? What does it mean to textual (unique); as an integral yet set-apart personalize care in an age of evidence-based med- member of the community, the shaman works icine? necessarily within a very specific metaphorical Despite the problematic, potentially explosive space. The buffalo may speak to the Sioux and nature of religious and even spiritual engagement, the rose to the mystical Muslim; other symbols we cannot afford to discard the shaman. Within the may speak to the white Protestant from Idaho. patient’s room, Walker took time to reflect. In- copyright. Walker enjoyed an increasingly rare circum- deed, the family privileged his silence with their stance; he knew his patients not only from living own. Whether by his powers of intuition or reason, among them but because, it seemed, he was one but most likely both, he entered the Dorsetts’ of them. Walker embodied a specific community skulls. He then invoked a familiar but transforma- in his healing practice. tive ritual space. I surmise that Walker, in this Most of us practice among patients of diverse move, saved our health care system tens of thou- religious, ethnic, and cultural beliefs and values. sands of dollars in operative, anesthetic, rehabilita-

We rarely encounter patients who match up to us. tive, and psychiatric costs. (Completely rational http://www.jabfm.org/ In contemporary society we can hardly predict the care may be highly irrational.) Moreover, his solu- continuation of a faith tradition from father to son. tion was deeply healing for the family. I do not What if Walker had been wrong in his estimation know what Walker meant by the word “Savior.” It of the patient’s and family’s belief system? What if is possible that his and the family’s definitions and there was apathy or even antipathy toward the beliefs differed substantially. Did Walker intend to Christian cosmology by a few or even one member invoke a heavenly host (incantation) or was he re- of the family? To add to these dangers, we must minding the family of the limits of science and on 30 September 2021 by guest. Protected recognize the danger of mixing religion and med- technology (revelation)? Whatever his intentions, icine: a patient’s trust in the physician’s curative his singular intervention manifest his profound powers may shift seamlessly and inappropriately agility within a shared metaphorical world. His into trust of the physician’s ethical or religious words also marked the moment when, for me, authority, even when the physician intends only to modern physician and ancient shaman became, for engage and not impose. But in this specific con- the good of our patients, one. text, Walker’s use of religion did not seem to limit or oppress. Rather, his transcendent words The author wishes to thank Chase Peterson, Rebecca de cut through the veneer of ordinary cognition into Schweinitz, Michael Magill, Alistair Bahar, and Susan Cochella deeper sensibilities, opening the family into a for important feedback on this essay.

796 JABFM November–December 2010 Vol. 23 No. 6 http://www.jabfm.org