No one wants to end up in hospital. The experience of illness or injury is unpleasant at the best, and spiritually devastating at worst. It doesn’t help that hospitals are often impersonal and hostile places where one struggles to get the care that one needs. Two years of a global pandemic have only exacerbated the stress on hospitals, with staff shortages and resource scarcity leading to a situation in which people are, ironically, avoiding hospital as much as they would illness itself.
The impersonal, unwelcoming character of many hospitals, however, is not solely the result of COVID-19. Nor is there an easy economic or material explanation for the fact that many people feel uneasy and uncomfortable in hospitals, as if “more government funding” or “increased efficiency” would provide an answer to the dehumanisation of the delivery of healthcare in contemporary hospitals. The issue is just as much an existential and spiritual matter as it is an economic or material one. As bioethicist Charles Camosy has recently written:
contemporary medicine has limited itself to an “immanent frame” that focuses its attention completely on physical human flourishing … [P]hysicians are being robbed by their own secularized culture of the change to engage their patients (and to engage the practice of medicine itself) with explicit attention [to] transcendent human goods.
The alienation that people experience in hospitals, in other words, is not just the result of a depletion of material resources like beds in the intensive care unit (ICU) and surgical equipment, or human resources like nurses or doctors. It is also a matter of a depletion of spiritual resources — the kinds of resources that allow a doctor to be fully present to her patients, and to accompany them along the journey of illness and injury.
Part of the solution to this spiritual crisis lies in a rediscovery of the virtue of hospitality — a virtue that was once at the centre of what we might call the hospital project. Hospitality provides a framework for accompanying patients along the journey of illness and injury. Policy-makers should look to this forgotten virtue to discover what it really means to welcome the stranger and create a healthcare environment that allows for healing of both body and soul. It would greatly complement already existing and promising developments in contemporary healthcare, such as the flourishing of the hospice movement.
Hospitality and the hospital project
Ironically, hospitals are, in their origins, places where one would seek refuge rather than somewhere that one would seek to avoid. Early hospitals were closely linked to Christianity and the monasticism and religious life of the Middle Ages. Religious orders such as Knights Hospitaller built hospitals to care for pilgrims on their way to sacred sites in Europe and the Holy Land. Hospitals were a kind of one-stop in which pilgrims could find lodging and food, healthcare if they needed it, and spiritual care from the religious and priests who staffed the institution. Indeed, the oldest surviving hospital in the world, the Hôtel-Dieu in Paris (literally, “God’s hostel”), was originally a multipurpose institution which catered for the sick and poor, offering shelter, food, and medical care.
The mission of these institutions was much richer than a humanitarian goal of providing lodging and healthcare to friend and foe alike. Medieval Christian hospitals were profoundly oriented by an ethos of charity and concern for souls; and activities of worship, piety, and spiritual counsel were just as much a part of the life of the institution as were the provision of lodging and healthcare. “Sickness and death were not individual experiences”, writes historian Elaine Stratton Hild. On the contrary, illness had a deeply spiritual and communal dimension, and monks sought to provide both spiritual and medical support to the infirm. By way of example, Stratton Hild provides an account of physical illness and religious practice in the life of a typical fourteenth-century Augustinian monastery:
The leader of the community, the prior, came to the brother’s sickbed to hear his confession. The others gathered and processed to the infirmary with oil for anointing, incense, the communion host, a cross, and candles. They assembled in the room, singing antiphons and psalms as their sick brother was anointed. After the anointing, the brothers arranged a schedule so that at least one person remained always at his bedside.
While we cannot presume that this was the norm in every medieval hospital, it provides some indication of the ethos that underpinned these institutions.
Sickness and death in the medieval hospital, then, were a spiritual and communal matter. Readers might be tempted to reject this historical account as pietistic Christian propaganda. But the medieval hospital movement was not confined to the institutions of Christian Europe. On the contrary, The United States National Library of Medicine credits the hospital as being a product of medieval Islamic civilisation.
In Islam, there exists a moral imperative to treat the ill regardless of financial status. With this goal in view, medieval Islamic rulers established large and elaborate institutions such as the Qalawun Complex in Cairo, a multipurpose healthcare facility built by Sultan Qalawun in 1283-1285 CE. Such institutions served several purposes: they were a centre of medical treatment, a convalescent home for those recovering from illness or accidents, an asylum for people with mental illness, and a retirement home giving basic maintenance needs for the aged and infirm who lacked a family to care for them.
A philosophy of hospitality
The notion of hospitality, however — conceived of as social virtue whereby one welcomes strangers into one’s home and provides spiritual and material care — has received perhaps its richest elaboration within the Christian tradition. The parable of the Good Samaritan provides a uniquely clear and detailed articulation of one’s obligation to care for strangers. In the parable, a Samaritan — a man who, for racial and cultural reasons, ought to have been deeply hostile to Jews — rescues a gravely wounded Jewish priest from the roadside near Jerusalem, binds his sores, anoints him with oil and wine, and takes him to an inn for rest and care. Hospitality, then, is most fully expressed when one is tasked with caring for someone who is a complete stranger — when the only possible reason for offering refuge is the perception of the guest’s need.
What does it mean to welcome a stranger into one’s home? The 20th century French existentialist philosopher Gabriel Marcel suggested that expressions such as “being at home” and “being in another’s home” are best understood in terms of a harmony that one has with one’s surrounds. Where we are trying to understand what it means to be “in another’s home”, we must go beyond a conception of the subject being alienated from their own familiar surrounds, towards an understanding of the self-giving and communion that occurs when one subject welcomes another into their home. Thus, Marcel wrote in his 1964 book Creative Fidelity, “to provide hospitality is truly to communicate something of oneself to the other”.
Integral to understanding Marcel’s work is his notion of disponibilité (roughly translated as “availability” or “disposability”). According to Marcel, all personal relationships exist on a spectrum ranging from alienation to communion, and they are to some extent defined by the manner in which each subject makes themselves “available” to the other. To say that a subject is truly available to the other is to say that they have put all their resources, material, intellectual, emotional, and spiritual, at the service of the other — to treat the other as a subject, not an object.
The challenge of hospitality in contemporary hospitals
Unfortunately, physicians today are educated in such a way that they are led to be wary of emotional attachment and cautious of spirituality. The hidden curriculum of medicine is all too often one in which physicians are led to protect themselves from the emotional engagement that humanly they may feel drawn to have with their patients. This is not just a psychological defence mechanism; it’s got to do with the way we think about medicine as being distinct from other forms of social support — in particular, spirituality care. As Harvard physicians Tracy and Michael Balboni put it, “most clinicians are amazingly compassionate persons, but a separation of medicine from spiritual resources is now increasingly taking its toll on our social systems aimed to care for and heal the seriously ill”.
On the contrary, we need to allow individual clinicians to be fully open and available to patients. This requires adequate medical resources and good staffing ratios, but it also requires a fundamental change in culture. Marcel’s conceptualisation of human relationships is particularly relevant to understanding the challenges of the physician-patient relationship today. The challenge for individuals in the modern world is to see others as a unique individual and not a “case to be solved”. Illness is the real problem, and patients should not be led to feel like a number or diagnostic category rather than a human being with their own unique subjectivity.
From hostility to hospitality in the 21st century hospital
The virtue of hospitality is more important to hospitals in the 21st century than it arguably ever has been before. Lacking an adequate understanding of hospitality, hospitals have gone from institutions that welcome strangers and provide a home, to becoming institutions that often alienate patients and make them long for home. This is not to say that hospitals ought to take on roles that they need not play. It is good, for example, that people are increasingly choosing to die at home rather than in hospital.
We need, in a modest way, however, to correct the course of the contemporary hospital movement. Hospitals need to rediscover the tradition of welcoming guests and to think about what it means to provide authentic care for strangers. Nobody wants to end up in hospital. But we never feel more at home than in the presence of someone who really cares for us.
Naysayers will no doubt cynically categorise this idea as an economically naïve proposition (“how many billions of dollars would such a proposal cost?”). But to some extent this is not a question of additional funding, but of what money can’t buy — the human face of healthcare.
This essay has been republished from ABC Religion & Ethics with permission