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Religion, Culture, and Nursing

Dimensions of Religion

Religion is complex and multifaceted in both form and function. Religious faith and the institutions derived from that faith become a central focus in meeting the human needs of those who believe. The majority of faith traditions address the issues of illness and wellness, of disease and healing, of caring and curing (Ebersole, Hess, & Luggan, 2008; Fogel & Rivera, 2010; Leonard & Carlson, 2010).

Religious Factors

Influencing Human Behavior First, it is necessary to identify specific religious factors that may influence human behavior. No single religious factor operates in isolation, but rather exists in combination with other religious factors and the person’s ethnic, racial, and cultural background. When religion and ethnicity combine to influence a person, the term ethnoreligion is sometimes used. Examples of ethnoreligious groups include the Amish, Russian Jews, Lebanese Muslims, Italian, Irish, or Polish Catholics, Tibetan Buddhists, American Samoan Mormons, and so forth. Faulkner and DeJong (1966) have proposed five major dimensions of religion in their classic work on the subject: experiential, ritualistic, ideologic, intellectual, and consequential.

Experiential Dimension The experiential dimension recognizes that all religions have expectations of members and that the religious person will at some point in life achieve direct knowledge of ultimate reality or will experience religious emotion. Every religion recognizes this subjective religious experience as a sign of religiosity.

Ritualistic Dimension The ritualistic dimension pertains to religious practices expected of the followers and may include worship, prayer, participation in sacraments, and fasting

Ideologic Dimension The ideologic dimension refers to the set of beliefs to which its followers must adhere in order to call themselves members. Commitment to the group or movement as a social process results, and members experience a sense of belonging or affiliation.

Intellectual Dimension The intellectual dimension refers to specific sets of beliefs or explanations or to the cognitive structuring of meaning. Members are expected to be informed about the basic tenets of the religion and to be familiar with sacred writings or scriptures. The intellectual and the ideologic are closely related because acceptance of a dimension presupposes knowledge of it.

Consequential Dimension The consequential dimension refers to religiously defined standards of conduct and to prescriptions that specify what followers’ attitudes and behaviors should be as a consequence of their religion. The consequential dimension governs people’s relationships with others.

Religious Dimensions in Relation to Health and Illness Obviously, each religious dimension has a different significance when related to matters of health and illness. Different religious cultures may emphasize one of the five dimensions to the relative exclusion of the others. Similarly, individuals may develop their own priorities related to the dimension of religion. This affects the nurse providing care to clients with different religious beliefs in several ways. First, it is the nurse’s role to determine from the client, or from significant others, the dimension or combinations of dimensions that are important so that the client and nurse can have mutual goals and priorities. Second, it is important to determine what a given member of a specific religious affiliation believes to be important. The only way to do this is to ask either the client or, if the client is unable to communicate this information personally, a close family member. Third, the nurse’s information must be accurate. Making assumptions about clients’ religious belief systems on the basis of their cultural, ethnic, or even religious affiliation is imprudent and may lead to erroneous inferences. The following case example illustrates the importance of verifying assumptions with the client. Observing that a patient was wearing a Star of David on a chain around his neck and had been accompanied by a rabbi upon admission, a nurse inquired whether he would like to order a kosher diet. The patient replied, “Oh, no. I’m a Christian. My father is a rabbi, and I know it would upset him to find out that I have converted. Even though I’m 40 years old, I hide it from him. This has been going on for 15 years now.” The key point in this anecdote is that the nurse validated an assumption with the patient before acting. Furthermore, not all Jewish persons follow a kosher diet nor wear a Star of David. Fourth, even when individuals identify with a particular religion, they may accept the “official” beliefs and practices in varying degrees. It is not the nurse’s role to judge the religious virtues of clients but rather to understand those aspects related to religion that are important to the client and family members. When religious beliefs are translated into practice, they may be manipulated by individuals in certain situations to serve particular ends; that is, traditional beliefs and practices are altered. Thus, it

is possible for a Jewish person to eat pork or for a Catholic to take contraceptives to prevent pregnancy. Although some find it necessary to label such occurrences as exceptional or accidental, such a point of view tends to ignore the fact that change can and does occur within individuals and within groups. Homogeneity among members of any religion cannot be assumed. Perhaps the individual once embraced the beliefs and practices of the religion but has since changed his or her views, or perhaps the individual never accepted the religious beliefs completely in the first place. It is important for the nurse to be open to variations in religious beliefs and practices and to allow for the possibility of change. Individual choices frequently arise from new situations, changing values and mores, and exposure to new ideas and beliefs. Few people live in total social isolation, surrounded by only those with similar religious backgrounds. Fifth, ideal norms of conduct and actual behavior are not necessarily the same. The nurse is frequently faced with the challenge of understanding and helping clients cope with conflicting norms. Sometimes conflicting norms are manifested by guilt or by efforts to minimize or rationalize inconsistencies. Sometimes norms are vaguely formulated and filled with discrepancies that allow for a variety of interpretations. In religions having a lay organization and structure, moral decision making may be left to the individual without the assistance of members of a church hierarchy. In religions having a clerical hierarchy, moral positions may be more clearly formulated and articulated for members. Individuals retain their right to choose regardless of official church-related guidelines, suggestions, or even religious laws; however, the individual who chooses to violate the norms may experience the consequences of that violation, including social ostracism, public removal from membership rolls, or other forms of censure.

Social ostracism is especially problematic for those clients experiencing mental illness (Fayard, Harding, Murdoch, & Brunt, 2007; Fogel & Rivera, 2010; Matthew, 2008; Yurkovich & Lattergrass, 2008).

Religion and Spiritual Nursing Care

For many years, nursing has emphasized a holistic approach to care in which the needs of the total person are recognized. Most nursing textbooks emphasize the physical and psychosocial needs of clients rather than ways to address spiritual needs (Black, 2009; Ebersole et al., 2008; Fayard et al., 2007; Yurkovich & Lattergrass, 2008). Comparatively little has been written about guidelines for providing spiritual care to clients from diverse cultural backgrounds. Because nurses endeavor to provide holistic health care, addressing spiritual needs becomes essential. Religious concerns evolve from and respond to the mysteries of life and death, good and evil, and pain and suffering. Although the religions of the world offer various interpretations of these phenomena, most people seek a personal understanding and interpretation at some time in their lives. Ultimately, this personal search becomes a pursuit to discover a Supreme Being, God, gods, or some unifying truth that will give meaning, purpose, and integrity to existence (Ebersole et al., 2008; Keehl, 2009; Leonard & Carlson, 2010; Yurkovich & Lattergrass, 2008). Before spiritual care for culturally diverse clients is discussed, an important distinction needs to be made between religion and spirituality. Derived from Latin roots, the term religion means to tie or hold together, to secure, bind, or fasten. It refers to the establishment of a system of attitudes and beliefs. Religion refers to an organized system of beliefs concerning the cause, nature, and purpose of the universe, especially belief in or the worship of a Supreme Being who is called by various names according to ethnoreligious traditions and beliefs. Among the important functions of religion is to create and nurture communal and individual spirituality. Religious activities often include reading scriptures or sacred writings (e.g., Qu’ran, Torah, Bible), praying, singing, and/or participating in individual or communal worship services (Leonard & Carlson, 2010). Spirituality is born out of each person’s unique life experience and his or her personal effort to find purpose and meaning in life. When people search for meaning or for a connection that transcends themselves, they are acting as spiritual beings. Spirituality exists in connections to others, the environment and the universe that lies beyond human experience. It refers to an ultimate reality. Present in all individuals, spirituality may be expressed as inner peace, and strength (Buck, 2006; Keehl, 2009; Narayanasamy, 2006; Yuen, 2007).

Spirituality encompasses “embracing, celebrating and voicing all the connections with the ultimate/mystery/divine, within me and beyond me, in experiences that give me meaning, purpose, direction, and values for my daily journey” (Leonard & Carlson, 2010; Spirituality in Healthcare Module, p. 1). While religion and spirituality have similarities and overlapping concepts, they are separate and distinct from one another (Black, 2009; Buck, 2006; Keehl, 2009). In general, religion addresses questions related to what is true and right and helps individuals determine where they belong in the scheme of their life’s journey. Spirituality emphasizes the pursuit of meaning, purpose, direction, and values.

Spiritual Nursing Care The goal of spiritual nursing care is to assist clients in integrating their own religious beliefs about a Supreme Being or a unifying truth into the ultimate reality that gives meaning to their lives. This is especially meaningful when people face a serious health challenges or crisis that precipitated the need for nursing care in the first place. Spiritual nursing care promotes clients’ physical and emotional health as well as their spiritual health. When providing care, the nurse must remember that the goal of spiritual intervention is not, and should not be, to impose his or her religious beliefs and convictions on the client (Amos, 2007; Gordon, 2006; Hubbell, Woodard, Barksdale-Brown, & Parker, 2006; Keehl, 2009; Tzeng & Yin, 2006; Yuen, 2007). Although spiritual needs are recognized by many nurses, spiritual care is often neglected. Among the reasons why nurses fail to provide spiritual care are the following: (1) they view religious and spiritual needs as a private matter concerning only an individual and his or her Creator; (2) they are uncomfortable about their own religious beliefs or deny having spiritual needs; (3) they lack knowledge about spirituality and the religious beliefs of others; (4) they mistake spiritual needs for psychosocial needs; and (5) they view meeting the spiritual needs of clients as a family or pastoral responsibility, not a nursing responsibility. Spiritual intervention is as appropriate as any other form of nursing intervention and recognizes that the balance of physical, psychosocial, and spiritual aspects of life is essential to overall good health. Nursing is an intimate profession, and nurses routinely inquire without hesitation about very personal matters such as hygiene and sexual habits. The spiritual realm also requires a personal, intimate type of nursing intervention (Black, 2009; Gordon, 2006; Hubbell et al., 2006; Keehl, 2009; Tzeng & Yin, 2006; White, 2007). In North America, efforts to integrate spiritual care and nursing have been under way for approximately four decades. In 1971 at the White House Conference on Aging, the spiritual dimension of care was defined as those aspects of individuals pertaining to their inner resources, especially their ultimate concern, the basic value around which all other values are focused, the central philosophy of life that guides their conduct, and the supernatural and nonmaterial dimensions of human nature.

The spiritual dimension encompasses the person’s need to find satisfactory answers to questions about the meaning of life, illness, or death (Ebersole et al., 2008; Jett & Touhy, 2010; Keehl, 2009; Moberg, 1971, 1981; Yuen, 2007). In 1978, the Third National Conference on the Classification of Nursing Diagnoses recognized the importance of spirituality by including “spiritual concerns,” “spiritual distress,” and “spiritual despair” in the list of approved diagnoses. Because of practical difficulties, these three categories were combined at the 1980 National Conference into one category, spiritual distress, which is defined as disruption in the life principle that pervades a person’s entire being and that integrates and transcends the person’s biologic and psychosocial nature. Moberg (1981) acknowledges the multidimensional nature of spiritual concerns and defines them as the human need to deal with sociocultural deprivations, anxieties and fears, death and dying, personality integration, self-image, personal dignity, social alienation, and philosophy of life.

Assessment of Ethnoreligious and Spiritual Issues

As discussed in Chapter 3, cultural assessment includes assessment of the relationship between religious and spiritual issues as they relate to the health care status of clients. In the integration of health care and religious/spiritual beliefs, the focus of nursing intervention is to help the client maintain his or her own beliefs in the face of a serious health challenge or crisis and to use those beliefs to strengthen the client’s coping patterns. If the religious beliefs are contributing to the overall health problem (e.g., guilt, remorse, expectations), you can conduct a spiritual assessment. To be therapeutic, begin by asking questions that clarify the problem, and nonjudgmentally support the client’s problem solving (Buck, 2006; Hubbell et al., 2006; Keehl, 2009; Yhlen & Ashton, 2006; Yuen, 2007; Yurkovick & Lattergrass, 2008). Box 13-1 Assessing Spiritual Needs in Clients from Various Ethnoreligious Backgrounds What do you notice about the client’s surroundings? • Does the person have religious objects, such as the Qur’an (Koran) Bible, prayer book, devotional literature, religious medals, rosary, or other type of beads, photographs of historic religious persons or contemporary religious leaders (e.g., Catholic Pope, Dalai Lama, or image of another religious figure), paintings of religious events or persons, religious sculptures, crucifixes, objects of religious significance at entrances to rooms (e.g., holy water founts, a mezuzah, or small parchment scroll inscribed with an excerpt from scripture), candles of religious significance (e.g., Paschal candle, menorah), shrine, or other item? • Does the person wear clothing that has religious significance (e.g., head covering, undergarment, uniform)? Does the hair style connote affiliation with a certain ethnoreligious group, for example, earlocks worn by Hasidic Jewish men? • Are get well greeting cards religious in nature or from a representative of the person’s church, mosque, temple, synagogue, or other religious congregation? How does the person act?

• Does the person appear to pray at certain times of the day or before meals? • Does the person make special dietary requests (e.g., kosher diet, vegetarian diet, or refrain from caffeine, pork or pork derivatives such as gelatin or marshmallows, shellfish, or other specific food items)? • Does the person read religious magazines or books? What does the person say? • Does the person talk about God (Allah, Buddha, Yahweh, Jehova), prayer, faith, or religious topics? • Does the person ask for a visit by a clergy member or other religious representative? • Does the person express anxiety or fear about pain, suffering, dying or death? How does the person relate to others? • Who visits? How does the person respond to visitors? • Does a priest, rabbi, minister, elder, or other religious representative visit? • Does the person ask the nursing staff to pray for or with him/her? • Does the person prefer to interact with others or to remain alone? Summarized in Box 13-1 are guidelines for assessing spiritual needs in clients from diverse cultural backgrounds (Figure 13-1).

Spiritual Nursing Care for Ill Children and Their Families

In a broad sense, any hospitalization or serious illness can be viewed as stressful and therefore has the potential to develop into a crisis. You may find that religion plays an especially significant role when a child is seriously ill and in circumstances that include dying, death, or bereavement. Illness during childhood may be an especially difficult clinical situation. Children as well as adults have spiritual needs that vary according to their developmental level and the relative importance of religion and spirituality in the lives of their primary providers of care. Parental perceptions about the illness of their child may be partially influenced by religious beliefs. For example, some parents may believe that a transgression against a religious law has caused a congenital anomaly in their offspring. Other parents may delay seeking medical care because they believe that prayer should be tried first. FIGURE 13-1 This statue commemorates the Roman Catholic Saint Martin De Porres. Born in Peru during the 16th century to a Spanish father and a Black mother, Martin De Porres studied medicine, which he later, as a member of the Dominican Order, put to use in helping the poor. He is honored by some Catholics as the patron saint of African Americans. When assessing the needs of clients from diverse backgrounds, nurses can observe for the presence of religious objects in the client’s home or yard (© Copyright M. Andrews).

The nurse should be respectful of parents’ preferences regarding the care of their child. When you believe that parental beliefs or practices threaten the child’s well-being and health, you are obligated to discuss the matter with the parents. It may be possible to reach a compromise in which parental beliefs are respected and necessary care is provided. On rare occasions, it may become a legal matter (Fogel & Rivera, 2010; Matthew, 2008). Religion may be a source of consolation and support to parents, especially those facing the unanswerable questions associated with lifethreatening illness in their children.

Spiritual Nursing Care for the Dying or Bereaved

Client and Family All people do not mourn alike. Mourning is a form of cultural behavior, and it is manifest in a multicultural society. Mourning customs help people cope with the loss of loved ones. Nurses inevitably focus on restoring health or on fostering environments in which the client returns to a previous state of health or adapts to physical, psychological, or emotional changes. However, one aspect of care that is often avoided or ignored, though every bit as crucial to clients and their families, is death and the accompanying dying and grieving processes. Death is indeed a universal experience, but one that is highly individual and personal. Although each person must ultimately face death alone, rarely does a person’s death fail to affect others. There are many rituals, serving many purposes, that people use to help them cope with death. These rituals are often determined by cultural and religious orientation. Situational factors, competing demands, and individual differences are also important in determining the dying, bereavement, and grieving behaviors that are considered socially acceptable (Amos, 2007).

The role of the nurse in dealing with dying clients and their families varies according to the needs and preferences of both the nurse and client, as well as the clinical setting in which the interaction occurs. By understanding some of the cultural and religious variations related to death, dying, and bereavement, the nurse can individualize the care given to clients and their families. Nurses are often with the client through various stages of the dying process and at the actual moment of death, particularly when death occurs in a hospital, nursing home, extended care facility, or hospice. The nurse often determines when and whom to call as the impending death draws near. Knowing the religious, cultural, and familial heritage of a particular client as well as his or her devotion to the associated traditions and practices may help the nurse determine whom to call when the need arises.

Religious Beliefs Associated with Dying

Universally, people want to die with dignity. Historically this was not a problem when individuals died at home in the presence of their friends and families. Now, when more and more people are dying in institutions (hospitals, hospices, and extended care facilities) ensuring dignity throughout the dying process is more complex. Once death is seen as a problem for professional management, the hospital displaces the home, and specialists with different kinds and degrees of expertise take over for the family (Amos, 2007). The way in which people commemorate death tells us much about their attitude and philosophy of life and death. Although it is beyond the scope of this book to explore the philosophic and psychological aspects of death in detail, some points will be made that relate to nursing care.

Preparation of the Body

A nurse may or may not actually participate in the rituals associated with death. When people die in the United States and Canada, they are usually transported to a mortuary, where the preparation for burial occurs. In many cultural groups, preparation of the body has traditionally been very important. Whereas members of many cultural groups have now adopted the practice of letting the mortician prepare the body, there are some, particularly new immigrants, who want to retain their native and/or religious customs. For example, for certain Asian immigrants it is customary for family and friends of the same sex to wash and prepare the body for burial or cremation. In other situations, the family or religious representatives may go to the funeral home to prepare the body for burial by dressing the person in special religious clothing. If a person dies in an institution, it is common for the nursing staff to “prepare” the body according to standard procedure. Depending on the ethnoreligious practices of the family, this may be objectionable—the family members may view this washing as an infringement on a special task that belongs to them alone. If the family is present, you should ask family members about their preference. If ritual washings will eventually take place at the mortuary, you may carry out the routine procedures and reassure the family that the mortician will comply with their requests, if that has in fact been verified. North American funeral customs have been the topic of lively discussion. The initial preparation of the body has been described in the following way: “After delivery to the undertaker, the corpse is in short order sprayed, sliced, pierced, pickled, trussed, trimmed, creamed, waxed, painted, rouged and neatly dressed…transformed from a common corpse into a beautiful memory picture. This process is known in the trades as embalming and restorative art, and is so universally employed in North America that the funeral director does it routinely without consulting the corpse’s family. He regards as eccentric those few who are hardy enough to suggest it might be dispensed with. Yet no law requires it, no religious doctrine commends it, nor is it dictated by considerations of health, sanitation or even personal daintiness. In no part of the world but in North America is it widely used. The purpose of embalming is to make the

corpse presentable for viewing in a suitably costly container, and here too the funeral director routinely without first consulting the family prepares the body for public display” (Kalish & Reynolds, 1981, p. 65). This extensive preparation and attempt to make the body look “alive,” “just as he used to,” or “just as if she were asleep” may reflect the fact that North Americans have come into contact with death and dying less than have other cultural groups

Funeral Practices

By their very nature, people are social beings who need to develop social attachments. When these social attachments are broken by death, people need to bring closure to the relationships. The funeral is an appropriate and socially acceptable time for the expression of sorrow and grief. Although there are some mores that dictate acceptable behaviors associated with the expression of grief, such as crying and sobbing, the wake and funeral are generally viewed as times when members of the living social network can observe and comfort the grieving survivors in their mourning, and say a last goodbye to the dead person. It is important to keep in mind that even the terms used for the wake and the funeral may vary according to religious and cultural beliefs. What is called a wake in many North American religions may be called a viewing or Home going by others. Customs for disposal of the body after death vary widely. Muslims have specific rituals for washing, dressing, and positioning the body. In traditional Judaism, cosmetic restoration is discouraged, as is any attempt to hasten or retard decomposition by artificial means. As part of their lifelong preparation for death, Amish women sew white burial garments for themselves and for their family members (Wenger, 1991). For the viewing and burial, faithful Mormons are dressed in white temple garments. Burial clothes and other religious or cultural symbols may be important items for the funeral ritual. If such items are present, you should ensure that they are taken by the family or sent to the funeral home. Believing that the spirit or ghost of the deceased person is contaminated, some Navajos are afraid to touch the body after death. In preparation for burial, the body is dressed in fine apparel, adorned with expensive jewelry and money, and wrapped in new blankets. After death, some Navajos believe that the structure in which the person died must be burned. There are specific members of the culture whose role is to prepare the body and who must be ritually cleansed after contact with the dead. Funeral arrangements vary from short, simple rituals to long, elaborate displays. Among the Amish, family members, neighbors, and friends are relied on for a short, quiet ceremony. Many Jewish families use unadorned coffins and stress simplicity in burial services. Some Jews fly the body to Jerusalem for burial in ground considered to be holy. egardless of economic considerations, some groups believe in lavish and costly funerals.

Religious Trends in the United States and Canada The United States and Canada are cosmopolitan nations to which all of the major and many of the minor faiths of Europe and other parts of the globe have been transplanted. Religious identification among people from different racial and ethnic groups is important because religion and culture are interwoven. Table 13-1 details the statistical breakdown of major religious affiliations of the United States and Canada (Figure 13-2). Selected religious groups and their respective memberships numbers in the United States and Canada are identified in Table 13-2. As discussed, a wide range of beliefs frequently exists within religions —a factor that adds complexity. Some religions have a designated spokesperson or leader who articulates, interprets, and applies theological tenets to daily life experiences, including those of health and illness. These leaders include Jewish rabbis, Catholic priests, and Lutheran ministers. Some religions rely more heavily on individual conscience, whereas others entrust decisions to a group of individuals, or to a single person vested with ultimate authority within their religious tradition.

Although it is impossible to address the health-related beliefs and practices of any religion adequately, this chapter offers a brief overview of selected groups. Some of the world’s religions fall into major branches or divisions, such as Vaishnavite and Shaivite Hinduism; Theravada and Mahayana Buddhism; Orthodox, Reform, and Conservative Judaism; Roman Catholic, Orthodox, and Protestant Christianity; and Sunnite and Shi’ite Islam. There also are subdivisions into what are often called denominations, sects, or schools of thought and practice.

Catholic Charities

USA, an umbrella agency that oversees nonhospital work, reports that its agencies serve more than 10 million people each year, often functioning as a centralized referral source for clients ultimately treated in non-Catholic agencies (accessed at http://www.catholiccharitiesusa.org/ on March 1, 2010). Similarly, there are many Jewish hospitals, day care centers, extended care facilities, and organizations to meet the health care needs of Jewish and non-Jewish persons in need. For example, the National Jewish Center for Immunology and Respiratory Medicine is a research and treatment center for respiratory, immunologic, allergic and infectious diseases, whereas the Council for Jewish Elderly provides a full range of social and health care services for seniors, including adult day care, care/case management, counseling, transportation, and advocacy. Box 13-2 Internet Websites for Selected Religions According to the Pew Forum on Religion and Public Policy, many other denominations, including the Lutheran, Mennonite, Methodist, Muslim, and Seventh-Day Adventist groups, own and operate hospitals and health care organizations similar to those described previously (accessed on March 1, 2010 at http://pewforum.org/docs). In Canada, hospital care, outpatient care, extended care, and medical services have been publicly funded and administered since the Medical Care Act of 1966. However, before the Medical Care Act and into the present, religious organizations have made important contributions to the health and well-being of Canadians at individual, community, and societal levels. For example, countless church-run agencies, charities, and facilities offer care and social support to individuals and families coping with such conditions as chronic illness, disability, poverty, and homelessness. At the national level, church-run organizations, such as the Catholic Health Association of Canada, are committed to addressing social justice issues that affect the health system and offer leadership through research and policy development regarding health care ethics, spiritual and religious care, and social justice. The remainder of this chapter will provide an overview of selected religions and their health-related beliefs and practices. The religious groups have been listed in alphabetical order. For a quick online overview of religious beliefs and practices for various groups, refer to Box 13-2.

Amish

The term Amish refers to members of several ethnoreligious groups who choose to live separately from the modern world through manner of dress, language, family life, and selective use of technology. There are four major orders or affiliating groups of Amish: (1) Old Order Amish, the largest group, whose name is often used synonymously with “the Amish”; (2) the ultraconservative Swartzentruber and Andy Weaver Amish, both more conservative than the Old Order Amish in their restrictive use of technology and shunning of members who have dropped out or committed serious violations of the faith; (3) the less conservative New Order Amish, which emerged in the 1960s with more liberal views of technology but with an emphasis on high moral standards in restricting alcohol and tobacco use and in courtship practices; and (4) the Liberal Beachy Amish. The total population of Amish is estimated at 160,000, spread throughout more than 220 settlements in 21 states and one Canadian province (about 1/20th of 1% of the total populations of the United States and Canada). In 1900, there were approximately 5,000 Amish, representing the number who immigrated to the United States during the 18th and 19th centuries. During the 20th century, however, the population grew as the Amish became less frequent targets for conversion and growing numbers of children (80–85%) chose, as adults, to be baptized Amish. As a result, the population grew to 85,000 by 1979 and has nearly doubled today. More than half are younger than age 18 (Donnermeyer, 1997).

General Beliefs and Religious Practices

The imperative to remain separate is the common theme of the nearly 500year history of the Amish and is based on the following scripture passages: “Be not conformed to this world, but be ye transformed by the renewing of your mind” (Romans 12:2) “Be ye not unequally yoked together with unbelievers; for what fellowship hath righteousness with unrighteousness? and what communion hath light with darkness?” (II Corinthians 6:14) The Amish are direct descendants of a branch of Anabaptists (which means “to be rebaptized”) which emerged during the Protestant Reformation and resided in Switzerland, The Netherlands, Austria, France, and Germany. Anabaptists stressed adult baptism, separation from and nonassimilation with the dominant culture, conformity in dress and appearance, marriage to others within the group, nonproselytization, nonparticipation in military service, and a disciplined lifestyle with an emphasis on simple living. These basic tenets remain today. A former Catholic priest from The Netherlands named Menno Simmons (1496–1561) wrote down the beliefs and practices of the Anabaptists, who became known as Mennonites. In 1693, under the leadership of a church elder named Jacob Ammann (1656–1730), a more conservative group broke away and formed the group currently known as the Amish.

Core Characteristics According to Donnermeyer’s (1997) classic study, there are five core characteristics of the Amish

Subculture First, the Amish are a subculture: a group with beliefs, values, and behaviors which are distinct from the greater culture of which the group is a part. The Amish maintain their separateness and distinctiveness from United States and Canadian societies in a variety of ways. Geographically, the Amish live close together in areas referred to as settlements and rely primarily on the horse and buggy or bicycles for transportation. The Amish continue to practice their faith in the tradition of Anabaptism, which includes small church districts of a few dozen families led by a bishop, church services that rotate from house to house of each family (no church building), the practice of adult baptism, communion twice a year, and shunning. Church leaders are chosen through a process of nomination and drawing by lot, and they serve for life. All but a few Amish marry, extended family remains important, and divorce is rare. The Amish dress in distinctive clothing (plain colors and mostly without buttons and zippers). They speak a form of German among themselves known as Pennsylvania Dutch or High German, and they sometimes refer to non-Amish as the “English.”

Ordung

The second core feature of the Amish is the ordung, which is used for passing on religious values and way of life from one generation to the next. Parts of the ordung are based on specific biblical passages, but much of it consists of rules for living the Amish way.

Meidung/Shunning

The third characteristic of the Amish is meidung, the practice of shunning members who have violated the ordung. After all members of the church district have discussed the case and agreed to impose meidung, the individual is separated from the rest of his or her community. It is the church’s method of enforcing the ordung. Meidung is an important way of maintaining both a sense of community among Amish and a sense of separation from the rest of the world. Sanctions for violations against important values, beliefs, and behaviors that define distinctiveness from the majority culture enable the Amish to retain their religious and cultural identity. In most cases, when meidung is applied, it is for a limited time. Meidung applies only to Amish adults who have been baptized, not to their unbaptized children. Children of Amish who choose not to be baptized often become members of neighboring Mennonite congregations and maintain contact with their Amish relatives. With less serious violations of the ordung, a member is visited privately by the deacon and a minister, and the matter is resolved quietly. For more serious offenses, the punishment is carried out publicly during a church service. A few offenses, such as adultery and divorce, are automatically conditions of excommunication. By displaying deep sorrow and repentance for an offense, excommunicated members can be allowed back, but this is not easily accomplished.

Selective Use of Technology

The fourth core characteristic is the selective use of technology. The Amish selectively use many modern technologies, but only if this does not threaten their ability to maintain a community of believers. Technologically, the Amish restrict the use of electricity in their homes and farms, and they limit their use of telephones. Although they ride in automobiles, trains, and airplanes, they do not operate them. Tractors for farm field work might reduce the opportunity for sons and daughters to help parents with farm chores, and the farm would become larger, reducing the number available for future generations. Thus, technology is not inherently ad, but when its consequences result in destruction of family and community life, it is avoided

Gelassenheit

The fifth and final core characteristic of the Amish is gelassenheit. This term means “submission,” or yielding to a higher authority, and it represents a general guide for behavior among Amish members. Gelassenheit represents the high value that the Amish place on maintaining a sense of community, which is accomplished by not drawing too much attention to one’s self. Amish cite gelassenheit as the reason they avoid having their photographs taken and prohibit mirrors in their homes.

Holy Days and Sacraments

Amish hold church services every other Sunday on a rotating basis in the homes or barns of church district members. The church services last several hours with hymns, scriptures, and services in High German or Pennsylvania Dutch. The family hosting the services is expected to provide a meal for all in attendance. Christmas celebrations include family dinners and exchange of gifts. Weddings last all day and include eating and singing. An important part of Amish life is informal visiting. Families often visit one another without advance notice, and it is common for unexpected visitors to stay for a meal. Amish observe adult baptism and communion twice a year.

Social Activities (Dating, Dancing)

The Amish strive for high standards of conduct in both their private and public lives. This includes chastity before marriage and humility in dress, language, and behavior. The function of dating is to afford individuals an opportunity to become acquainted with each other’s character. Couples contemplating marriage may engage in a practice called bundling, in which they lie together in bed, fully clothed, without having sexual contact.

Substance Use Alcoholic beverages and drugs are forbidden unless prescribed by a physician. Tobacco use is prohibited.

Health Care Practices

Illness is seen as the inability to perform daily chores; physical and mental illness are equally accepted. Health care practices within the Amish culture are varied and include folk, herbal, homeopathic, and Western biomedicine. Unlike the use of episodic biomedicine, however, preventive medicine may be seen as against God’s will. The use of the Western biomedical health care system is largely episodic and crisis oriented. If Western biomedicine fails, there is no hesitancy in visiting an herb doctor, pow-wow doctor (a practitioner of a folk healing art, known as brauche, in which touch is used to heal), or a chiropractor. Folk, professional, and alternative care are often used simultaneously. Cost, access, transportation, and advice from family and friends are the major factors that influence healing choices (Wenger, 1990).

Medical and Surgical Interventions

The use of narcotic drugs is prohibited. There are no restrictions against the use of blood, blood products, or vaccines if advised by health care providers

Practices Related to Reproduction Birth Control

Baha’is believe that the fundamental purpose of marriage is the procreation of children. Individuals are encouraged to exercise their discretion in choosing a method of family planning. Baha’u’llah taught that to beget children is the highest physical fruit of man’s existence. The Baha’i teachings imply that birth control constitutes a real danger to the foundations of social life. It is against the spirit of Baha’i law, which defines the primary purpose of marriage to be the rearing of children and their spiritual training. It is left to each husband and wife to decide how many children they will have. Baha’i teachings state that the soul appears at conception. Therefore, it is improper to use a method that produces an abortion after conception has taken place (e.g., intrauterine device). Methods that result in permanent sterility are not permissible under normal circumstances. If situations arise that justify sterilization (e.g., removal of cancerous reproductive organs), those called upon to make the decision would rely on the best medical advice available and their own consciences.

Amniocentesis Amniocentesis is permitted if advised by health care providers.

Abortion Members are discouraged from using methods of contraception that produce abortion after conception has taken place (e.g., intrauterine device). A surgical operation for the purpose of preventing the birth of an unwanted child is strictly forbidden. Baha’i teachings state that the human soul comes into being at conception. Abortion and surgical operations for the purpose of preventing the birth of unwanted children are forbidden unless circumstances justify such actions on medical grounds. In this case, the decision is left to the consciences of those concerned, who must carefully weigh the medical advice they receive in the light of the general guidance given in the Baha’i writings.

Artificial Insemination Although there are no specific Baha’i writings on artificial insemination, Baha’is are guided by the understanding that marriage is the proper spiritual and physical context in which the bearing of children must occur. Couples who are unable to bear children are not excluded from marriage, because marriage has other purposes besides the bearing of children. The adoption of children is encouraged.

Eugenics and Genetics The Baha’is view scientific advancement as a noble and praiseworthy endeavor of humankind. Baha’i writings do not specifically address these two branches of science.

Religious Support System for the Sick Individual members of local and surrounding communities assist and support one another in time of need. Religious titles are not used. Individual members of local communities look after the needs of the sick.

Practices Related to Death and Dying Because human life is the vehicle for the development of the soul, Baha’is believe that life is unique and precious. The destruction of a human life at any stage, from conception to natural death, is rarely permissible. The question of when natural death has occurred is considered in the light of current medical science and legal rulings on the matter. Autopsy is acceptable in the case of medical necessity or legal requirement. Baha’is are permitted to donate their bodies for medical research and for restorative purposes. Local burial laws are followed. Unless required by state law, Baha’i law states that the body is not to be embalmed. Cremation is forbidden. The place of burial must be within 1 hour’s travel from the place of death. This regulation is always carried out in consultation with the family, and exceptions are possible.

Buddhist Churches of America

Buddhism is a general term that indicates a belief in Buddha and encompasses many individual churches. There are approximately 900,000 Buddhists in North America, and the worldwide membership is greater than 600 million. The Buddhist Churches of America is the largest Buddhist organization in mainland United States. This group belongs to the largest subsect of Jodo Shinshu Buddhism (Shin Buddhism), Honpa Hongwanji, which is the largest traditional sect of Buddhism in Japan. The Jodo Shinshu sect was started in Japan and its headquarters are in Kyoto, Japan. The group of churches in Hawaii is a different organization of Shin Buddhism, called Honpa Hongwanji Mission of Hawaii. There are numerous Buddhist sects in the United States and Canada, including Indian, Sri Lankan, Vietnamese, Thai, Chinese, Japanese, Tibetan, and so on. Buddhism was founded in the 6th century B.C. in northern India by Gautama Buddha. In the 3rd century B.C., Buddhism became the state religion of India and spread from there to most of the other Eastern nations. The term Buddha means “enlightened one.” At the beginning of the Christian era, Buddhism split into two main groups: Hinayana, or southern Buddhism, and Mahayana, or northern Buddhism. Hinayana retained more of the original teachings of Buddha and survived in Sri Lanka (formerly Ceylon) and southern Asia. Mahayana, a more social and polytheistic Buddhism, is strong in the Himalayas, Tibet, Mongolia, China, Korea, and Japan.

General Beliefs and Religious Practices

Buddha’s original teachings included Four Noble Truths and the Noble Eightfold Way, the philosophies of which affect Buddhist responses to health and illness. The Four Noble Truths expound on suffering and constitute the foundation of Buddhism. The truths consist of (1) the truth of suffering, (2) the truth of the origin of suffering, (3) the truth that suffering can be destroyed, and (4) the way that leads to the cessation of pain. The Noble Eightfold Way gives the rule of practical Buddhism, which consists of (1) right views, (2) right intention, (3) right speech, (4) right action, (5) right livelihood, (6) right effort, (7) right mindfulness, and (8) right concentration. Nirvana, a state of greater inner freedom and spontaneity, is the goal of all existence. When one achieves Nirvana, the mind has supreme tranquility, purity, and stability. Although the ultimate goals of Buddhism are clear, the means of obtaining those goals are not religiously prescribed. Buddhism is not a dogmatic religion, nor does it dictate any specific practices. Individual differences are expected, acknowledged, and respected. Each individual is responsible for finding his or her own answers through awareness of the total situation.

Holy Days

“The major Buddhist holy day is Saga Dawa (or Vesak) which is the observance of Sakyamuni Buddha’s birth, enlightenment and parinirvana. This holiday falls during the months of May or June. It is based on a Lunar calendar, and therefore the actual date varies from year to year.” (Figure 13-4). Although there is no religious restriction for therapy on those days, they can be highly emotional, and a Buddhist patient should be consulted about his or her desires for medical or surgical intervention. Some Buddhists may fast for all or part of this day.

Sacraments Buddhism does not have any sacraments. A ritual that symbolizes one’s entry into the Buddhist faith is the expression of faith in the Three Treasures (Buddha, Dharma, and Sangha). FIGURE 13-4 A Buddhist woman lights incense in remembrance of deceased ancestors during the Chinese New Year celebration (© Copyright M. Andrews).

Diet Moderation in diet is encouraged. Specific dietary practices are usually interconnected with ethnic practices. Some branches of Buddhism have strict dietary regulations, for example, vegetarianism, while others do not. It is important to inquire the patient’s preferences.

Health Care Practices

Buddhists do not believe in healing through a faith or through faith itself. However, Buddhists do believe that spiritual peace, and liberation from anxiety by adherence to and achievement of awakening to Buddha’s wisdom, can be important factors in promoting healing and recovery.

Medical and Surgical Interventions

There are no restrictions in Buddhism for nutritional therapies, medications, vaccines, and other therapeutic interventions, but some individuals may refrain from alcohol, stimulants, and other drugs that adversely affect mental clarity. Buddha’s teaching on the Middle Path may apply here; he taught that extremes should be avoided. What may be medicine to one may be poison to another, so generalizations are to be avoided. Medications should be used in accordance with the nature of the illness and the capacity of the individual. Whatever will contribute to the attainment of Enlightenment is encouraged. Treatments such as amputations, organ transplants, biopsies, and other procedures that may prolong life and allow the individual to attain Enlightenment are encouraged.

Practices Related to Reproduction

The immediate emphasis is on the person living now and the attainment of Enlightenment. If practicing birth control or having an amniocentesis or sterility test will help the individual attain Enlightenment, it is acceptable. Buddhism does not condone the taking of a life. The first of Buddha’s Five Precepts is abstention from taking lives. Life in all forms is to be respected. Existence by itself often contradicts this principle (e.g., drugs that kill bacteria are given to spare a patient’s life). With this in mind, it is the conditions and circumstances surrounding the patient that determine whether abortion, therapeutic or on demand, may be undertaken.

Religious Support System for the Sick

Support of the sick is an individual practice in keeping with the philosophy of Buddhism, but Buddhist priests often render assistance to those who become ill.

Practices Related to Death and Dying

If there is hope for recovery and continuation of the pursuit of Enlightenment, all available means of support are encouraged. If life cannot be prolonged so that the person can continue to search for Enlightenment, conditions might permit euthanasia. If the donation of a body part will help another continue the quest for Enlightenment, it might be an act of mercy and is encouraged. The body is considered but a shell; therefore, autopsy and disposal of the body are matters of individual practice rather than of religious prescription. Burials are usually a brief graveside service after a funeral at the temple. Cremations are common.

Religious Objects Prayer beads and images of Sakyamuni Buddha and other Buddhist deities may be utilized for specific prayer or meditation practices.

Addendum

The headquarters of the Buddhist Churches of America is at 1710 Octavia Street, San Francisco, California 94109 (Telephone: [415] 776-5600). Additional material is available at the Buddhist Bookstore of the Buddhist Churches of America Headquarters. Information on Buddhism and temple locations in Canada can be found at http://buddhismcanada.com

Catholicism (According to the Roman Rite)

With a North American membership of approximately 97 million and a worldwide membership of more than 1 billion, some 32 rites exist within Catholicism. Of these, the Roman Rite is the major body.

General Beliefs and Religious Practices

The Roman Catholic Church traces its beginnings to about A.D. 30, when Jesus Christ is believed to have founded the church. Catholic teachings, based on the Bible, are found in declarations of church councils and Popes and in short statements of faith called creeds. The oldest and most authoritative of these creeds are the Apostle’s Creed and the Nicene Creed, the latter being recited during the central act of worship, called the Eucharistic Liturgy, or Mass. The creeds summarize Catholic beliefs concerning the Trinity and creation, sin and salvation, the nature of the church, and life after death.

Holy DaysCatholics are expected to observe all Sundays (including Easter Sunday) as holy days. Sunday or holy day worship services may be conducted any time from 4:00 pm on Saturday until Sunday evening. Other days set aside for special liturgical observance are: Christmas (December 25th), Solemnity of Mary, Mother of God ( January 1st), Ascension Thursday (the Lord’s ascension bodily into Heaven, observed 40 days after Easter), Feast of the Assumption (August 15th), All Saints Day (November 1st), and the Feast of the Immaculate Conception (December 8th).

Sacraments

The Roman Catholic Church recognizes seven sacraments: Baptism, Reconciliation (formerly Penance or Confession), Holy Communion or the Eucharist (Figure 13-5), Confirmation, Matrimony, Holy Orders, and Anointing of the Sick (formerly Extreme Unction).

Religious Objects Rosaries, prayer books, and holy cards are often present and are of great comfort to the patient and their family. They should be left in place and within the reach of the patient whenever possible (Accessed on March 1, 2010 at http://www.catholichealthcare.us/).

Diet (Foods and Beverages)

The goods of the world have been given for use and benefit. The primary obligation people have toward foods and beverages is to use them in moderation and in such a way that they are not injurious to health. Fasting in moderation is recommended as a valued discipline. There are a few days of the year when Catholics have an obligation to fast, which means to abstain from meat and meat products. Catholics fast and abstain on Ash Wednesday and Good Friday, and abstinence is required on all of the Fridays of Lent. The sick are never bound by this prescription of the law. Healthy persons between the ages of 18 and 62 are encouraged to engage in fasting and abstinence as described. FIGURE 13-5 In the Roman Catholic tradition, when children reach the age of reason (about 7 years), they continue the ongoing initiation into their religion by making their First Communion. In addition to the religious ritual, there are sometimes cultural traditions surrounding this event, many of which involve a family celebration after the religious services have concluded (© Copyright M. Andrews).

Social Activities (Dating, Dancing) The major principle is that Sunday is a day of rest; therefore, unnecessary servile work is prohibited. The seven holy days are also considered days of rest, although many persons must engage in routine work-related activities on some of these days.

Substance Use

Alcohol and tobacco are not evil per se. They are to be used in moderation and not in a way that would be injurious to one’s health or that of another party. The misuse of any substance is not only harmful to the body but also sinful.

Health Care Practices

In time of illness, the basic rite is the Sacrament of the Sick, which includes anointing of the sick, communion if possible, and a blessing by a priest. Prayers are frequently offered for the sick person and for members of the family. The Eucharistic wafer (a small unleavened wafer made of flour and water) is often given to the sick as the food of healing and health. Other family members may participate if they wish to do so.

Medical and Surgical Interventions

As long as the benefits outweigh the risk to the individuals, judicious use of medications is permissible and morally acceptable. A major concern is the risk of mutilation. The Church has traditionally cited the principle of totality, which states that medications are allowed as long as they are used for the good of the whole person. Blood, blood products, and amputations are acceptable if consistent with the principle of totality. Biopsies and circumcision are also permissible. The transplantation of organs from living donors is morally permissible when the anticipated benefit to the recipient is proportionate to the harm done to the donor, provided that the loss of such an organ does not deprive the donor of life itself or of the functional integrity of his or her body.

Practices Related to Reproduction Birth Control

The basic principle is that the conjugal act should be one that is lovegiving and potentially life-giving. Only natural means of contraception, such as abstinence, the temperature method, and the ovulation method are acceptable. Ordinarily, artificial aids and procedures for permanent sterilization are forbidden. Birth control (anovulants) may be used therapeutically to assist in regulating the menstrual cycle.

Amniocentesis

The procedure in and of itself is not objectionable. However, it is morally objectionable if the findings of the amniocentesis are used to lead the couple to decide on termination of the pregnancy or if the procedure injures the fetus.

Abortion

Direct abortion is always morally wrong. Indirect abortion may be morally justified by some circumstances (e.g., treatment of a cancerous uterus in a pregnant woman). Abortion on demand is prohibited. The Roman Catholic Church teaches the sanctity of all human life, even of the unborn, from the time of conception.

Sterility Tests and Artificial Insemination The use of sterility tests for the purpose of promoting conception, not misusing sexuality, is permitted. Although artificial insemination has been debated heavily, traditionally it has been looked on as illicit, even between husband and wife.

Eugenics, Genetics, and Stem Cell Research

Research in the fields of eugenics and genetics is objectionable. This violates the moral right of the individual to be free from experimentation and also interferes with God’s right as the master of life and human beings’ stewardship of their lives. Some genetic investigations to help determine genetic diseases may be used, depending on their ends and means. There is support for research using adult stem cells, but opposition for the use of embryonic stem cells.

Religious Support System for the Sick

Visitors Although a priest, deacon, or lay minister usually visits a sick person alone, the family or other significant people may be invited to join in prayer. In fact, that is most desirable, since they too need support. The priest, deacon, or lay minister will usually bring the necessary supplies for administration of the Eucharist or administration of the Sacrament of the Sick (in the case of a priest). The nursing staff can facilitate these rites by ensuring an atmosphere of prayer and quiet and by having a glass of water on hand (in case the patient is unable to swallow the small wafer-like host). Consecrated wine can be made available but is usually not given in the hospital or home. The nurse may wish to join in the prayer. Candles may be used if the patient is not receiving oxygen. The priest, deacon, or lay minister will usually appreciate any information pertaining to the patient’s ability to swallow. Any other information the nurse believes may help the priest or deacon respond to the patient with more care and effectiveness would be appreciated, but HIPPA laws must be remembered and information that violates privacy not divulged. Catholic lay persons of either gender may visit hospitalized or homebound elderly or sick persons. Although they may not administer the Sacrament of the Sick or the Sacrament of Reconciliation, they may bring Holy Communion (the Eucharist).

Title of Religious Representative

The titles of religious representatives include Father (priest), Mr. or Deacon (deacon), Sister (Catholic woman who has taken religious vows), and Brother (Catholic man who has taken religious vows).

Environment During Visit by Religious Representative

Privacy is most conducive to prayer and the administration of the sacraments. In emergencies, such as cardiac or respiratory arrest, medical personnel will need to be present. The priest will use an abbreviated form of the rite and will not interfere with the activities of the health care team.

Church Organizations to Assist the Sick

Most major cities have outreach programs for the sick, handicapped, and elderly. More serious needs are usually handled by Catholic Charities and other agencies in the community or at the local parish level. Organizations such as the St. Vincent DePaul Society may provide material support for the poor and needy as well as some counseling services, depending on the location. In the United States, the Catholic Church owns and operates hospitals, extended care facilities, orphanages, maternity homes, hospices, and other health care facilities. Although the majority of tertiary care facilities in Canada are publicly owned, many such institutions are strongly influenced by the leadership of the Catholic Church and its members. It is usually best to consult the pastor or chaplain in specific cases for local resources.

Practices Related to Death and Dying

Prolongation of Life (Right to Die) Members are obligated to take ordinary means of preserving life (e.g., intravenous medication) but are not obligated to take extraordinary means. What constitutes extraordinary means may vary with biomedical and technologic advances and with the availability of these advances to the average citizen. Other factors that must be considered include the degree of pain associated with the procedure, the potential outcome, the condition of the patient, economic factors, and the patient’s or family’s preferences.

Euthanasia

Direct action to end the life of patients is not permitted. Extraordinary means may be withheld, allowing the patient to die of natural causes.

Autopsy and Donation of Body

This is permissible as long as the corpse is shown proper respect and there is sufficient reason for doing the autopsy. The principle of totality suggests that this is justifiable, being for the betterment of the person who does the giving.

Disposal of Body and Burial

Ordinarily, bodies are buried. Cremation is acceptable in certain circumstances, such as to avoid spreading a contagious disease. Because life is considered sacred, the body should be treated with respect. Any disposal of the body should be done in a respectful and honorable way.

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