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MAKING ROOM FOR SPIRITUALITY IN ETHICAL DECISION-MAKING IN END
OF LIFE CARE: WIDE REFLECTIVE EQUILIBRIUM IN PRACTICE

presented by

Ruth Ann Rashid

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MAKING ROOM FOR SPIRITUALITY IN ETHICAL DECISION-MAKING IN END
OF LIFE CARE: WIDE REFLECTIVE EQUILIBRIUM IN PRACTICE

By

Ruth Ann Rashid

A THESIS

Submitted to
Michigan State University
in partial fulﬁllment of the requirements
for the degree of

MASTER OF ARTS
Interdisciplinary Program in Health and Humanities

2002

ABSTRACT

MAKING ROOM FOR SPIRITUALITY IN ETHICAL DECISION-MAKIN G IN END
OF LIFE CARE: WIDE REFLECTIVE EQUILIBRIUM IN PRACTICE

By

Ruth Ann Rashid

The theory of wide reﬂective equilibrium (WRE) is a coherence theory of
morality, which holds much appeal because it seems to capture the method by which
many of us work toward making moral decisions in everyday life. By using this theory,
medical personnel and other relevant professionals, along with the patient and her family,
would be able to include the values of the patient in the decision-making process, thus
aiding them in making better decisions for patients at the end of life. '

However, part of making good decisions for patients involves ﬁnding out what it
is that gives life meaning for that patient. In order to get at what it is that gives such
meaning to the life a patient, medical personnel could begin the conversation by asking
about the patient’s spiritual convictions, values, and transcendental perspectives. As the
patient’s views come to light, they can easily be incorporated into the process of WRE.
Not only is it necessary to have these kinds of discussions with patients, but having these
' discussions and incorporating spirituality into the process of WRE can help to solve the
problem of justiﬁcation and the problem of comprehensiveness which exist for WRE and

its use as a moral theory.

ACKNOWLEDGEMENTS

I would like to extend my sincere thanks to those who have contributed to the
formation of this thesis. I would ﬁrst like to acknowledge the members of my thesis
committee. Thank you to Martin Benjamin, Ph.D. for helping me to better understand the
theory of wide reﬂective equilibrium and to see how one could be a nontheist and still
hold spiritual and transcendental values. Thank you to Clayton Thomason, J .D., M.Div.
for accompanying me through my struggle to “deﬁne” spirituality. Thank you to Tom
Tomlinson, Ph.D. for serving as the chair of my committee and therefore helping me to
pull it all together.

Finally, I would like to thank Tess Tavormina, Ph.D., director of the
Interdisciplinary Program in Health and Humanities for giving me the academic freedom
to explore disciplines that at times seemed ill-deﬁned and utterly irreconcilable. I hope

that this thesis begins to provide both definition and reconciliation.

iii

TABLE OF CONTENTS

INTRODUCTION ................................................................................... 1

CASE STUDY — A SPIRITUAL CRISIS ........................................................ 3

WIDE REFLECTIVE EQUILIBRIUM ........................................................... 5

SPIRITUALITY ...................................................................................... 8
Common Conceptions ....................................................................... 8
Limiting ‘Spirituality’ ....................................................................... 9
Spirituality in Practice ..................................................................... 12
Markers are not Enough ................................................................... 13

Spiritual Change when Faced with Death and the Importance of Conversation... 14

MAKING ROOM ................................................................................... 17
PROBLEMS WITH WIDE REFLECTIVE EQUILIBRIUM AND SOME POSSIBLE
SPIRITUAL SOLUTIONS .................................................................... 18
The Problem of Comprehensiveness .................................................... 18
The Problem of Justiﬁcation .............................................................. 24
POSSIBLE OBJECTIONS ........................................................................ 26
RESPONSES ........................................................................................ 27
THE THEORY IN PRACTICE ................................................................... 29
CONCLUSION ...................................................................................... 31
WORKSCITED.................... ............................................................... '.32

iv

INTRODUCTION

I recently conversed with someone about the various disciplines that can aid in
understanding bioethics. This individual was of the persuasion that the only place for a
graduate student to learn to understand bioethics is in a philosophy class. In my mind,
there are two notions of ‘understanding’ at work here.

In one sense, to ‘understand’ means to learn a particular language — in this case,
the language of bioethics. This is the kind of understanding that participation in a
graduate philosophy course can provide. It is in the ethics class that we learn what it
means to approach ethical dilemmas from the standpoint of the Kantian or utilitarian. It
is in the philosophy of science class that we learn that, from the Kuhnian perspective, the
ﬁeld of bioethics makes no sense because one can only call the practice of medicine into
question from within the practice itself, while from the Popperian perspective we see that
bioethicists can help us to discover the Truth, which exists independently of a discipline.
It is in a graduate seminar on narrative ethics that we learn that stories can help us to
solve ethical dilemmas, both by providing additional information about the case at hand
and by priming us for future dilemmas by seeing how other people’s dilemmas have
played out. Naturally, there is more to be learned ﬁ'om the advanced study of philosophy,
but that discussion is not my focus.

Rather, my focus is on another sense of what it means to ‘understand.’ To
‘understand’ means to appropriately apply. In this context, it is more than speaking the
language of the bioethicist; it is the meaningful application of that language to a
particular case or situation. Understanding, in the way I have deﬁned it, also necessitates
developing and making use of a diversiﬁed “toolbox.” The two tools that will be the
focus for the rest of my exploration are spirituality and wide reﬂective equilibrium.

In what follows, I will ﬁrst present a case in which it is evident that the patient is
undergoing a “spiritual crisis.” I will then provide explanations of wide reﬂective

equilibrium and spirituality, respectively. Next, I will show some possible places that

spirituality ﬁts into wide reﬂective equilibrium, while also providing possible solutions to
some of the problems that wide reﬂective equilibrium encounters. Finally, I will refer
back to the case presented at the beginning and demonstrate that through the process of
wide reﬂective equilibrium and considerations of spirituality, a good decision can be

made for a patient at the end of life.

CASE STUDY — A SPIRITUAL CRISIS
One of the possible origins of a spiritual crisis is a conﬂict between values that
one has held for most of one’s life and a particular situation in which one believes that
holding to that previously held belief would result in making the wrong decision.

Consider the following case.1

An 87-year old woman is dying of congestive heart failure. Tests predict
that she has less than a 50 percent chance to live for another six months.
She is lucid, assertive, and terriﬁed of death. She very much wants to live
and therefore kept opting for rehospitalization and the most aggressive
life-prolonging treatment available. That treatment has successfully
prolonged her life for two years, though it has meant that she is becoming
increasingly debilitated.

Given this view of the woman’s life and her illness, the decisions to continue treatment
seem to have been the right ones. This woman values her life and is afraid of death and
therefore, just by the fact that she has lived two more years, it seems as though things
have worked in her favor.

Now consider the following additional information.2

All her life, this woman has put the needs of her daughter before her own.
She prides herself on the fact that she was able to provide a good life for
her daughter who is now 55 years old.

We might at this point decide that it’s still in the best interest of the patient to have
continued with treatment and hospitalization. Since the patient had given so much to her

daughter, it seems as though something was due her. Perhaps we could consider it good

 

' This case study is a modified version of the case study found on pg. 37 of John Hardwig’s “Is there a duty
to die?” Hastings Center Report 27, no. 2 (1997): 34-42.

2 This information is a deviation from the case presented by Hardwig. Dr. Martin Benjamin suggested this
variant.

that the patient is ‘ﬁnally’ doing something good for herself. We might even imagine
that the patient’s daughter is herself beneﬁting from having the extra time with her
mother. Perhaps the patient is able to spend more time with her grandchildren. Maybe
she has used the last two years to get her affairs in order to make things easier on her
daughter. Maybe the patient’s desire to prolong her life was in the best interest of not
only herself, but her daughter as well.

But what if we include the following information about the situation that the

patient’s daughter is facing‘.73

Her 55-year-old daughter was her only remaining family, her caregiver,
and the main source of her ﬁnancial support. The daughter duly cared for
her mother. But before her mother died, her illness had cost the daughter
all of her savings, her home, her job, her career.

Once this information is made known, the conﬂict that the patient was facing becomes
clear. She had to decide if she should give into her fears about death and undergo every
possible treatment, or continue to hold to her previous convictions regarding her sense of
responsibility to her daughter. If the patient decides to forgo treatment, she must face her
fears about death. If she seeks treatment, she will be putting her daughter in a ﬁnancial

position from which she will most likely never recover. In this lies the spiritual conﬂict.

 

3 These aspects of the case are included in Hardwig’s presentation.

WIDE REFLECTIVE EQUILIBRIUM

In the case above the patient is faced with a situation that requires her choosing
between two convictions that she holds. Before the time of the conﬂict, she was able to
hold both of the convictions simultaneously, because they had never been challenged by
each other. The two convictions, up until the point of conﬂict, were reconcilable. At the
point of the conﬂict, the patient must decide which of the two convictions she wants to
hold in the particular situation. The other conviction must be given up. Wide reﬂective
equilibrium is a theory which systematized this process of deciding what to give up and
what to continue to hold.

Wide reﬂective equilibrium is a coherence theory of morality. This means that it
is striving for all components of moral theory to make sense in the light of one another.
In wide reﬂective equilibrium, the relevant components are considered moral judgments,
moral principles, and background beliefs and theories. Considered moral judgments are
those decisions that we make that result from moral deliberation. They are not decisions
made impulsively; rather, they are decisions that we spend at least some amount of time
considering. Moral principles are action-guiding rules. Background beliefs and theories
are those beliefs that we have held to over time. They can be based on our way of life or
other more general beliefs that play a part in our personal moral deliberation. They are
also memories of past experiences that play a role in guiding later action.

Norman Daniels describes the process of wide reﬂective equilibrium in the

following way:

We begin by collecting the person’s initial moral judgments and ﬁlter
them to include only those of which he is relatively conﬁdent and which
have been made under conditions conducive to avoiding errors of
judgment. For example, the person is calm and has had adequate
information about cases being judged. We then propose alternative sets of
moral principles that have varying degrees of “ﬁt” with the moral
judgments. We do not simply settle for the best ﬁt of principles with
judgments, however, which would give us only a narrow equilibrium.

Instead, we advance philosophical arguments intended to bring out the
relative strengths and weaknesses of the alternative sets of principles (or
competing moral conceptions). These arguments can be construed as
inferences from some set of relevant background theories (1 use the term
loosely). Assume that some particular set of arguments wins and that the
moral agent is persuaded that some set of principles is more acceptable
than the others (and, perhaps, than the conception that might have
emerged in narrow equilibrium). We can imagine the agent working back
and forth, making adjustments to his considered judgments, his moral
principles, and his background theories. In this way he arrives at an
equilibrium point that consists of the ordered triple (a), (b), (c)."

Daniels’s description of wide reﬂective equilibrium, although dense, does much
to illustrate the interaction of the three components; considered judgments, moral
principles, and considered moral judgments in wide reﬂective equilibrium. These
components make up the ordered triple that he refers to as (a), (b), (c). In order for wide
reﬂective equilibrium to be established, there must be coherence among the three
components. In other words, all of the components must make sense in light of one
another. According to Daniels, if there is no longer coherence among the relevant
components, the moral agent must identify the incoherence and decide what to change
among the components in order to reestablish coherence.

It can easily be argued that it is never possible for an individual to establish a true
coherence among the components. Rather, the moral agent continually strives for
coherence with the recognition that it will probably never be truly obtained. This
argument is made because wide reﬂective equilibrium must be wide, meaning that it must
be comprehensive as well as coherent. Because of the continual striving for increased
comprehensiveness, coherence will most likely never occur. The moral agent must
merely strive for coherence, not necessarily achieve it. If the moral agent is actively

pursuing comprehensiveness, then coherence will become more difﬁcult because there

 

4 Norman Daniels. “ Wide reﬂective equilibrium and theory acceptance in ethics.” As found in Justice and
Justification: Reﬂective equilibrium in praLtice. New York: Cambridge University Press. 1996. pg. 22.

will be increasingly more information to put into the mix. The greater the
comprehensiveness, the greater the amount of information and the more difﬁcult it
becomes for all of the information to be reconcilable. The question for the moral agent
engaged in wide reﬂective equilibrium then becomes one of how much of a lack of
coherence can be tolerated. (This issue of balance between coherence and
comprehensiveness deserves more exploration, but the attempt to establish a position on
this issue is beyond the scope of the relevant argument.)

In order to conceptualize wide reﬂective equilibrium, I have found it helpful to
think of one’s moral outlook as a network or web. In striving for coherence among the
components, one must continually reﬂect on the network and make sure that all of the
components maintain a nice ﬁt. The practice is wide because it involves reﬂection on the

whole of one’s moral outlook in an attempt to ﬁnd and maintain equilibrium.5

 

5 For additional information about wide reflective equilibrium, see John Rawls A Theog of Justice pg. 19-
21 and 48-51 and Norman Daniels “Wide Reﬂective Equilibrium and Theory Acceptance in Ethics” as
found in Justice and Justiﬁcation, pg. 21-46.

SPIRITUALITY
In considering what it means to be spiritual, one of the most important pieces of
information for us to keep in mind is that religion and spirituality are not the same.
Religion is almost always deﬁned as something institutional in nature. Religions are
bound by tradition and have a history. There is a prescribed way of practicing a
particular religion and to be a true believer, one must practice one’s faith in that

prescribed manner. Spirituality, on the other hand, is highly personal.

Common Conceptions

Many thinkers have tried to characterize what spirituality means. It is often
deﬁned as “wholeness,” but I have also heard it explained as a personal quest to “exceed
the limits.”6 Some say that all people can be considered spiritual because all people need
to have a way to make sense out of life. In “Spirituality Described,” Verna Carson
Brenner makes reference to spirituality as a “way of life.”7 Jake Foglio makes a
distinction between what he calls “religiously spiritual” and “secularly non-religiously
spiritual” individuals in order to label the distinction between religion and spirituality.8
Robert Wuthnow deﬁnes spirituality as a search. He notes that spirituality is no longer
something that is inherited from our parents, but is rather something that we develop
through the course of our lives. In this way, spirituality is no longer limited to afﬁliation

with religious organizations. It is highly personal and is apt to be in ﬂux throughout the

 

° The concept of spirituality as meaning “exceeding the limits” comes from Father Jake Foglio, Catholic
priest and retired professor. This statement was given in his lecture at the Second Annual Foglio
Conference on Spirituality and Medicine at Michigan State University on October 6, 2000.

7 Verna Carson Brenner. “Spirituality Described” Spirituﬁal Dimensions of Nursing Practice. W.B.
Saunders Co., 1989: 6-13.

8 Jake Foglio. “Spirituality and Medicine,” in “Spirituality: A Vital Component of Well Being.”
Coursepack for HM 548, Michigan State University College of Human Medicine, Spring 2001 , 26-29.

course of a lifetime.9 Spirituality involves more than just adherence to a particular set of
religiously-derived moral mandates. It requires personal exploration and growth.

In this sense, spirituality helps us along in our journey of life. Spirituality may be
as “simple” as our personal manifestation of organized religion, or it may be a complex
web of beliefs, outlooks on life, and practices that come from many different religions.
No matter where our spiritual practices come from, our spirituality can only come from

within us.

Limiting ‘Spiritualitv’

As is evident in the above characterizations of spirituality, many thinkers have
attempted to conceptualize spirituality so broadly that it then comes to lack
characterization.” When spirituality is deﬁned in such a way that everyone is then said
to be a spiritual person, the conception not only lacks meaning, but also moral weight. If
everyone is said to be spiritual, it becomes somewhat mundane (pardon the pun) to
inquire about whether or not someone identiﬁes herself as being a spiritual person.
Therefore, if spirituality is to be something that is really worth considering, some limits
need to be placed on its conception and formulation.

In order for spirituality to do the kind of moral work that I will be discussing later
on, I have chosen to deﬁne it in much the same way as Robert Wuthnow. As stated
above, Wuthnow views spirituality as an ongoing search. It is something that involves
personal exploration and growth. It is a dynamic process of seeking answers and insight.
There are three characteristics that I believe must play a role in this searching for it to be

considered spiritual. Spiritual seeking must be personal and intentional and while an

 

9 Robert Wuthnow. Aﬂer Heaven: Spirituality in America Since the 1950’s. University of California
Press, Berkley. 1998. Chapter 1.

'0 This concern was raised by Dr. Tom Tomlinson upon his review of an early draft of this exploration.

individual is engaged in the search, the individual maintain epistemic humilityll about
her beliefs. These three characteristics of spirituality require explanation.

In order for this kind of searching to be spiritual, it must be personal. That means
that it must focus on the beliefs of the person who is doing the seeking. Therefore, the
questions are not “What does my religion teach me?” or “What do my ﬁ'iends and family
believe?” Rather, the individual must be focused on what it is that creates meaning in her
life. She must be considering her beliefs. She might ask herself, for example, “What
tenets of my religion are important for me to incorporate in my life?” or “What have I
learned from family and friends that has helped me to become a better person?” In this
way, the focus of the searching must be the individual who is doing the searching. The
spiritual person is engaged in a process of self-discovery and reﬂection.

The searching must also be intentional. In order for a search to be spiritual, the
individual must recognize that she is searching. This means that she must realize the
process that she is undertaking. She must want to be engaged in the searching and must
take the necessary time for reﬂection and contemplation. For example, if a person takes a
yoga class in order to become more physically ﬂexible, that is not a spiritual activity.
But, if the same person takes the class because of her belief that it will enhance her
spiritual wellness, then it is a spiritual activity if she enters the class treating it as such.

Finally, the individual must maintain epistemic humility in relation to the results
of her spiritual search. She cannot dogmatically hold to beliefs and practices because
spiritual searching is an ongoing process. In the conception I have formulated for the
purposes of this exploration, spirituality does not have an endpoint at which the
individual can sit back and believe that she has found all of the answers to life’s

questions. '2 The individual may believe (though this is probably highly unlikely) that at

 

" The term “epistemic humility” was suggested by Clayton Thomason.

'2 I recognize that death, illness, and loss of mental ability may serve as a kind of end point for the spiritual
searches of some people, but that is not relevant here.

10

some point in time everything has become clear to her and all of the aspects of her life
make sense in the light of one another. Although this may happen, the individual cannot
just sit back and relax as a result of this newfound clarity. Rather, she must keep working
to test and try out her beliefs and the other products of her spiritual search.

Even though the spiritual person might believe that there is an eventual endpoint
' to her spiritual journey, most would probably realize that they will never see the endpoint
(at least while inhabiting their “earthly bodies”). For the spiritual person, the journey is
just as important as the destination. The struggles and difﬁculties of life are part of
what’s important to the spiritual person because it is through these struggles that the
individual is able to see more clearly what it is about life that gives it meaning.

Not only does spirituality not necessarily involve adherence to a particular
religion, but it also cannot involve the kind of strict dogmatic adherence to a set of beliefs
and rules that religious afﬁliation comes to mean for many religious people. People who
blindly follow the mandates of a religion already believe that they have all of the answers
to life’s questions. They believe about life (and life ever after) whatever it is that their
religion tells them to believe. They do not seek answers, because they believe that they
have already received all of the answers from their religion. Because these people are not
actively seeking insight and answers, they cannot be considered spiritual. The fact that
one can be religious and not be spiritual is just one more way that religion and spirituality
are not the same.

On the other side, people can be spiritual without being religious. Individuals can
seek insight and answers to transcendental questions without identifying with any
particular religion. Spiritual people can glean information and spiritual practices from a
variety of religions without ascribing to one religion in particular. Or their spirituality

can be entirely personal, a derivative of non-religious inﬂuences. For example, a person

11

can hold to the Socratic belief that the unexamined life is a life not worth living.13 This '
individual would spend time considering what it is about her life that gives it value. She
would think about the decisions that she makes and try to have them ﬁt in with the way
that she has lived her life up to that point. The ‘examined life’ will be discussed again

when the case study presented at the outset of this exploration is reconsidered.

Spiritgalitv in Practice

Because of the highly personalized nature of spirituality, it is vital that medical
professionals ask their patients about their beliefs and practices. There is no other way to
ﬁnd out what beliefs 3 patient holds about “the other.” Even though not all people
identify themselves as being spiritual, if they ﬁnd themselves in the hospital, most people
want (or at least would not mind) being questioned about their spiritual convictions,
values, and transcendental perspectives.

A survey was recently conducted of patients, which showed that sixteen percent
of patients did not want to be asked about their religion or spirituality while in the
hospital. This number may initially be disconcerting, but there is another interesting
trend that was discovered through conducting this survey. The results of the survey
showed that more than sixteen percent of the patients in this study stated that they were
not religious.14 Because we do not know the overlap of the categories based on the
presentation of the data, it is difﬁcult to make strong conclusions. What is interesting to
note, though, is that some believethat this shows that even individuals who do not
classify themselves as religious still want medical personnel to inquire about their

personal beliefs. Although I have not been able to ﬁnd empirical evidence to prove it, I

 

'3 Socrates states that “the life which is unexamined is not worth living” in “Apology.” At the time that
Socrates makes this statement, he is facing his own death, which makes his statement even more
meaningful in the context of this thesis.

'4 These statistics come from Dr. David Hufford’s keynote address at the Second Annual Foglio
Conference on Spirituality and Medicine at Michigan State University on October 6, 2000.

12

believe that the same could be said of spirituality. I believe that even though some
people may not identify themselves as being spiritual, that at least some people would
still want to be asked about their spiritual convictions, values, and transcendental
perspectives if faced with an illness or other condition which required their admission
into a hospital. There is reason to believe that even if they did not want to be asked such
things, that they would tolerate this questioning. (Although it may seem as though any
questioning would be of beneﬁt to the patient, that is not necessarily the case. I will
address this issue below, when the theory is discussed in practice.)

This kind of questioning and dialogue is even more important when it is
considered that it is not uncommon to have a bedside conversion or to fall back on a
particular set of beliefs that the patient dismissed long ago. Spirituality has the potential
to be a cohesive force in a personal narrative. For the spiritual person, her sense of
herself in the cosmos, the manner of her interaction with others, and her view of herself
as an individual may only be able to be understood through gaining insight into her
spirituality. By ignoring her spiritual convictions, values, and transcendental
perspectives, a vital component of who she is (and potentially her entire essence) is also

being ignored.

:Marlgers” are not Enough

As has been previously described, religion and spirituality are not the same and
spirituality is highly personal in nature. Therefore, when trying to gain access to and
understanding of the spiritual beliefs of a particular patient, it is not enough to have
looked at the medical chart of a patient to see that upon his admission to the hospital, he
checked the box on the form that signiﬁed he is Muslim. Just knowing that he has given
himself the identity marker of ‘Muslim’ does not help us to decide how to treat him.
Instead, those involved in the decision-making process need to take the information that

he is a Muslim and combine it with what is known about Islam. Then, we need to talk to

13

the patient. We need to ﬁnd out from the patient himself what it means for him to be
Muslim. It is only through dialogue with the patient that we would be able to see how
much it means to him to participate in particular religious practices. We also need to talk
with the patient to learn if his kind of Islam - his spirituality — is different from the
common conception that we hold of Islam. We cannot extend our generalizations about
the desires, motivations, and feelings of all Muslims to this particular Muslim before us,
because faith holds different meaning for different individuals - even for individuals who
claim the same religious faith. We have to consider that this man, who when called upon
to ﬁll in a checkbox chose that of Muslim, is a spiritual person who has relevant personal
convictions.

Identity markers, particularly those assigned by the patient himself can help us to
determine how to begin a conversation with a patient about his or her beliefs. For
example, we can begin by asking the patient what being Muslim means to him. In a
utopian situation, decisions about patient care would only be made after participation in
this sort of meaningful conversation. In reality, time and resources are limited, making it
difﬁcult for medical personnel to have the time adequately address these issues with the
patients in their care. Resource allocation and the amount of time spent with patients are
topics which are beyond the scope of this paper. However, I remain unwavering in my
conviction that conversations with patients (or their loved ones if the patient is unable to
communicate) is absolutely necessary in order for appropriate decisions to be made for a
patient at the end of life. It is up to hospital administrators and individual hospital
employees to determine methods by which to ensure that the necessary amount of time is

allotted for these conversations.

Spiritual Change when greed with Death and the Importance of Conversation
Another reason that we cannot rely totally on markers is that some markers do not

develop until the patient is forced to face his or her own mortality. A particular patient

14

may have ﬁlled out an admissions questionnaire without naming a next of kin or
checking the box next to a religion. After being admitted to the hospital, the patient may
face a terminal illness. In thinking about his or her life, the patient may become
remorseful at a failed relationship with his or her adult child. In thinking about death, the
patient may begin to cling to beliefs that he or she held as a child growing up in a
particular faith tradition or the individual may not ﬁnd the comfort in religion that he or
she once found. The patient may begin to develop a personal spirituality, because he or
she begins to question his or her religion and make changes to his or her personal beliefs
in light of the life changes that he or she is experiencing. As stated above, spirituality is
dynamic. Without conversation with the patient, no one would ever know that there
might be aspects of this person’s life that needed to be resolved before there is possibility
of a peaceful death.

It is not uncommon for individuals to cling to the faith that they formerly held
once they ﬁnd themselves “living in the light of death.”15 It is difﬁcult for many people
to face death with the thought that there is nothing waiting for them on the “other side.”
In many ways, the deathbed is the perfect place for the kinds of self-reﬂection and
transformation that spirituality inspires. It is the last chance that the individual has to
right former wrongs. It is the last opportunity for reconciliation. If while contemplating
her own mortality, the patient comes to realize that there are aspects of her life that she
wants to change, that is the beginning of a spiritual search. She begins her search by
recognizing that she has made mistakes. She then tries to identify some of those mistakes
and determine whether or not there is anything that can be done to correct them. Finally,
she puts her spiritual realization into practice by working to right whatever wrongs she is
able. She tries to re-ally herself with the cosmos by striving to be the person that she has

at times failed to be.

 

'5 In concept of “living in the light of death” comes from one of the patients who was a focus of one of
episodes of the Bill Moyers series on PBS entitled On Our Own Terms: Moyers on Dying.

15

Patients should be allowed and encouraged to be engaged in a process of
fundamental divergence from their life up to the time of their admission to the hospital.
Because those involved in end of life decision-making should be allowing for this kind of
radical transformation, they need to be constantly involved in conversation with the
patient to know where he or she is going to go next. We need to help them along with
their ﬁnal joumey and help them to make decisions about their end of life care based on
who they are now, not just who they were before. Although the past is part of who the
patient is now, there are morally relevant differences between a person who is healthy
and a person who is not. These differences need to be taken seriously if we are to work at
doing the best that we can for patients in the ﬁnal stages of life. Patients need to be able
to continue their spiritual journey until they draw their last breath. Room needs to be
made for patients to continue to develop their spiritual convictions, values, and
transcendental perspectives as long as they are able. To assume that patients confronting
the end of their life will be unwaveringly at peace with themselves, their spiritual
convictions, values, and transcendental perspectives, would be a horrible mistake.
Patients need to be allowed to outgrow previous identity markers and take up new ones.

They need to be given the room to continue to question. '6

 

'° At no point do I wish to say that all patients will undergo a deathbed conversion. In fact, many patients
probably remain basically the same people that they were before they entered the hospital.

16

MAKING ROOM

According to Daniels’s description of the ordered triple, there is room for
spirituality both as part of the body of moral principles and as part of the agent’s *
background beliefs and theories. Both of these components, in turn, impact the
considered moral judgments that are made by the agent.

Many spiritual people hold to a set of moral principles. These principles may
come from the teachings of the particular religion to which the agent ascribes, or they
may come from the agent’s conception of natural order, which are a part of the
worldview of the agent. For example, the agent may hold that it is wrong to kill another
person for gratuitous reasons. This principle may come from sacred texts, from a
conception of the sanctity of life, or from a utilitarian way of making sense of world.
This utilitarian ethic comes out of the realization that civilized society cannot persist if
members of society go around killing each other. The aggregate utility of society will be
hindered if members of society cannot leave their own home without trusting that they
will not be killed on their doorstep. The principles such as “do not kill” that are held by
the spiritual moral agent help to guide the agent’s decision-making processes.

Also, the background beliefs and theories as described by Daniels are impacted by
his or her spirituality. As stated earlier, background beliefs and theories are inﬂuenced
by the worldview of the agent. This kind of worldview can be formed through the
process of spiritual seeking. In actively searching for answers to life’s questions, the
spiritual person forms beliefs about herself and her place in the world which are relevant

kinds of background beliefs and theories.

17

PROBLEMS WITH WIDE REFLECTIVE EQUILIBRIUM AND SOME POSSIBLE
SPIRITUAL SOLUTIONS
In thinking more closely about wide reﬂective equilibrium, there seem to be two

major problems with its implementation as a moral practice. The ﬁrst problem is one that
I have previously alluded to. Wide reﬂective equilibrium places value on
comprehensiveness, but does not indicate how far one must go to achieve this
comprehensiveness. The second problem is that wide reﬂective equilibrium, as a
practice, does not help one to determine what course of action to take. In making a moral
decision, wide reﬂective equilibrium does not give any indication of why one equilibria
should be chosen over another. In what follows, I will address both of these concerns in

turn.

The Problem of Comprehen_siveness

Given that experience is necessary for engagement in wide reﬂective equilibrium,
the question of how one can adequately engage in wide reﬂective equilibrium becomes
one of width. By width, I mean that there is a range of possibility when it comes to how
far we need to push ourselves to test our moral outlook in wide reﬂective equilibrium.
As I see it, there are two extremes to this range. I call these extremes the moral hermit
and the moral chameleon.l7 It is my belief that neither of these extremes is the way to go
and that neither gets you to the kind of comprehensiveness that wide reﬂective
equilibrium requires. The concepts of the moral hermit and the moral chameleon require
explanation. .

The moral hermit is someone who has a moral outlook that basically goes

unchanged over time. This individual lives a life that reafﬁnns his moral system. He

 

'7 By describing these two extremes, I am not arguing that there are actually people in the world that live
and function at these extremes. I am just arguing that these extremes are the farthest that I believe people
could go with regard to the role of experience in wide reﬂective equilibrium.

l8

surrounds himself with like-minded people who do not call his moral system into
question. His life is rather dull. He is not open to new experiences because he is content
with his life the way that it is. He may be a morally commendable person and make
decisions that we all consider to be morally right, but he is not the kind of guy that most
of us would want to have dinner with, because his experiences are very limited. His
moral system is so static that it deﬁnes who he is and any change to his system would (in
his view) compromise his identity. Therefore, he is better off not changing his moral
system because, in his view, he would be compromising himself and his identity.18

At the other end of the spectrum is the moral chameleon. This is someone who is
constantly trying to experience new things and to push herself to try and see situations
from new perspectives. She hops from community to community, each time taking on
the values and moral system of that community. She is a traveler and leads what many
would consider to be an exciting life. She is someone that we would love to talk with,
but we fear letting her get to close to our children, because we never know what she
might be saying or doing next. She has no solid personal identity, because she adapts
herself to her surroundings and tries to ﬁt in. Her moral perspective is constantly in ﬂux
and there is no real continuity to her life story.

Obviously, neither of these extremes will get us to the goal of wide reﬂective
equilibrium. There has to be some middle ground. To establish this middle ground, I
now go back to the two points raised at the start of this section. First, in order to engage
in wide reﬂective equilibrium, we must be active in testing our moral system. We must

be open to new experience. The moral hermit totally isolates himself from experiences

 

'8 It might be argued that a moral hermit would not, in fact, be able to engage in wide reﬂective
equilibrium. However, I believe that the moral hermit could actually engage in moral reﬂection because of
new insight gained. The moral hermit might “accidentally” experience something that is new to him, thus
causing him to reﬂect on his moral system. The difference, though, is that the moral hermit would
probably be less likely to make changes in his considered judgments, moral principles, and background
beliefs and theories, because he believes that he will never have the same sort of “accidental” experience
again and therefore need not change his moral system. Thus, even after reﬂection, the moral hermit would
maintain the same moral system

19

that he thinks will lead him to have to reﬁne his moral system. He is like the scientist
who does not test her hypotheses out of a fear of being wrong. The moral hermit is not
engaging in wide reﬂective equilibrium in the proper way, if he can be said to be
engaging in it at all.

Secondly, it is my belief that engagement in wide reﬂective equilibrium requires
that we have novel experiences, but not too many. Also, the novel experiences need to
occur at great enough temporal intervals that we are able to do the moral work that wide
reﬂective equilibrium requires. We have to be able integrate the information that we
have learned from the novel experiences with our considered judgements, background
beliefs and theories, and moral principles. This kind of reﬂection takes time. The moral
chameleon does not allow herself the time to digest what her experiences mean with
regard to her moral framework. Because of her constant pushing to experience all that
she can and to live life to the fullest, she has lost herself and has no sense of personal
identity. She is not allowing herself to engage in wide reﬂective equilibrium because she
is not taking the time for reﬂection that it requires.

There is obviously a large middle ground between these two perspectives. In
order to discuss where exactly in this middle ground I believe that experiences should fall
in wide reﬂective equilibrium, I will begin by stating where is should not fall. Some
people are of the opinion that all that we need to do in order to engage in wide reﬂective
equilibrium is to be open to new experiences that have the potential to create conﬂict
within our moral system.19 From this openness, conﬂict may arise, or it may not. All
that matters is that we are open to reﬂecting on and possibly revising portions of our
moral system.

I do not believe that this position takes the role of testing through experience far

enough. We have to do more work than just being open to potential conﬂict. This

 

‘9 This view was articulated by Sonya Charles, philosophy doctoral candidate, Michigan State University.

20

position is too close to the moral hermit. Recall that even though the moral hermit in
many ways lives a life of isolation in which he just about guarantees that he will not have
to revise his moral perspective. Although he has not shut himself off totally from the
possibility that he will “accidentally” encounter something that will lead him to reﬂect on
his moral perspective, he has put erected a psychological banier against the experience of
conﬂict or challenge.20 Therefore, even though the hermit might accidentally come into
contact with something that poses a challenge to his worldview, he will not undergo the
self-reﬂection that is required to make sense of it. He has the experience, but does not
take the next step. The individual who lives a more normal life with the same kind of
openness to experience is not much better off.

In order to truly engage in wide reﬂective equilibrium, we need to do more than
wait around for a reason to reﬂect. We need to talk with those who hold different
positions from our own. We need to see how other people live and work and raise their
children. We need to move beyond our circle of like-minded friends. This is not to say
that we need to constantly be forcing ourselves to change our moral perspective. We
cannot go as far as the moral chameleon and still maintain our sense of identity. Instead,
we need to have a strong sense of identity if we are going to be able to hold on to
anything that we learn during our moral testing. If we do not know our own identity well
enough, we will not be able to have a coherent life story. Even though our life story may
include detours and backtracking, our sense of identity is what creates the coherent
whole. It is what binds our life story together. Without a sense of identity, we cannot
make sense of new experiences in a way that allows the new experiences to become a
part and remain a part of our life story. Without knowing who we are, we cannot decide

if something in our moral perspective needs to be reﬁned or replaced. We need to know

 

20 This concept of a “psycholigical banier” was articulated by Dr. Tom Tomlinson.

21

who we are and what we stand for before we can rationally change what we are as a
moral agent.

All of this said, it is clear that we need to do more in our quest for wide reﬂective
equilibrium than just be open to new experiences that are potential sources of moral
conﬂict. However, I have not made clear how far we need to go to seek out these
experiences. This is because how far we need to go is variable based on both the limits
of the individual and the intensity of the experience. First of all, by focusing on the
individual, we know that one cannot push oneself farther than the limits of reﬂection will
allow. What I mean by this is that one cannot experience more than one can make sense
of with respect to the whole of one’s moral system. As stated above, it takes time to
engage in the reﬂection demanded by wide reﬂective equilibrium. The reﬂection calls us
to ﬁnd coherence among our background beliefs and theories, moral principles, and
considered judgments. This is not something that can be done quickly and easily. Just
being able to identify and articulate our background beliefs and theories, moral principle,
and considered judgments takes time.21 The amount of time necessary for reﬂection will
vary from individual to individual and therefore cannot be marked as a ﬁxed point.

Secondly, the kinds of experiences we have are going to play a role in how much
work we need to do to test our moral perspective. For example, if we have an experience
that is unlike anything we have ever experienced before, it might take a lot longer to
make sense of and incorporate than something that is fairly similar to previous
experience. If we have an experience that shakes us at the core, like holding our dying
child in our arms, it may take a long time for us to regain some level of coherence in our
moral perspective. This experience may call into question our belief about a just God our

the belief that in the natural order of things, children outlive their parents. The

 

2' This is not to say that every time we engage in wide reﬂective equilibrium that we have to name all of
our considered judgments, moral principles, and background beliefs and theories. But it will take a lot of
time just to ﬁgure out which of these considered judgments, moral principles, and background beliefs and
theories are affected by the new information gained by a particular experience.

22

experience of losing your own child would call either or both of these beliefs into
question, which would then create a ripple effect throughout our moral network. If we
begin to question whether or not our god is just, we may then question all of the spiritual
convictions that we hold. This questioning will take a lot of time. This demonstrates that
the intensity of experience is another consideration in how far we need to go to seek out
new experiences. Some of the most intense experiences are probably ones that we do not
seek out. Even if we are trying to challenge ourselves and test our moral perspective, we
might not want to witness a murder or the atrocities of war. But, once we have an
experience like this, we have to make room for it in our moral perspective.

Further, I believe that spirituality, including the ideal of leading an examined life,
can play a role here. Recall that spirituality requires an active seeking for answers and
insight that is personal, intentional, and epistemically humble. While one is searching for
answers and insights, one can also be seeking out new kinds of experiences which may
pose a challenge to components of one’s moral web. In this way, those who are engaged
in spiritual pursuits do not fall into the category of a moral hermit. It seems to me that
the moral hermit can be viewed in much the same light as the blind-sighted adherent to a
particular religion. Neither is engaged in the kinds of searching necessary for wide
reﬂective equilibrium or for spirituality, because neither are epistemically humble in
relation to their beliefs.

Also, the spiritual person cannot be a moral chameleon. In order to really be
engaging in spiritual exploration, one must be reﬂective. As part of one’s spiritual
exploration, one must actively contemplate one’s spiritual perspective, values, and
considerations of the transcendent. This kind of personal reﬂection requires time, which
the moral chameleon would not have to devote to such consideration out of her constant
striving to have new and divergent experiences. The moral chameleon just wants to have
as many different experiences as possible, which does not leave her with much time to

work to incorporate anything new into her moral network.

23

If one is engaged in the kind of seeking that my formulation of spirituality
requires, one will be in the middle ground described earlier in this section. The spiritual
person will be searching for answers, many of which will come through experience. It is
hard to imagine many instances where an answer is bestowed upon an individual without
there being an experiential precursor which inspired the “discovery” of that answer.
Much of what we learn about the world and about ourselves comes from experience and
there is no reason to believe that what we incorporate into our spiritual life will derive

any differently.

The Problem of Justiﬁcation

The second problem with wide reﬂective equilibrium is that it does not help us to
decide between competing equilibria when it is necessary that we do so. When we are in
disequilibria, wide reﬂective equilibrium only guides us by informing us that there is a
choice to be made and than leaves it to us to make that choice. It does not help us to
determine which of the competing equilibria we would be better off adopting, the theory
just seems to assume that the proper choice will become apparent. However, if we are
choosing between discarding one piece of our moral network over another, it may not be
an easy choice. Both pieces must be of some value to us, otherwise they would not be
part of the network. It seems as though more guidance would be helpful in these
decisions.

Some guidance may come from our spirituality. A body of literature which is
particularly helpful here is that of pastoral care and counseling. Many people who seek
pastoral care and counseling are facing a difﬁcult time in their life and many of them
have to make some kind of decision. Lawrence Kohlberg has identiﬁed six stages of
moral reasoning and decision-making which I believe have some import here. According

to his stages:

24

...right is determined by: (l) obedience to authority to avoid punishment
and gain rewards; (2) instrumental hedonism (what satisﬁes one’s needs)
and some reciprocal fairness; (3) conformity to social expectations to gain
approval; (4) obeying rules and respecting authority (the law and order
stage); (5) respecting universal ethical principles; and (6) responding to
one’s inner vision of justice, love, and respect for all persons.22

According to this formulation, those with a sense of spirituality would be
functioning (for the most part) at level six. This is because the spiritual person would
have developed the “inner vision” which is necessary for functioning at this level. If an
individual is spiritual, she would be able to judge right and wrong from this higher level
because so much of her view of the world and her place in it would be able to be
articulated. Because she had spent time working out her inner vision of justice, reﬂecting
on what it means for her to love and to be loved by others, and learning what it means to
be in relationshipsbased on respect, she will be able to use these formulations as tools for
decision-making. It will make sense for her to work to base decisions on these
formulations because she has spent ’so much time and effort developing these

formulations.

 

‘2 Howard Clinbell. Basic Types of Pastoral Care and Counseling: Resources for the Minisg of Healing
and Growth. Abingdon Press: Nashville. 1984.

25

POSSIBLE OBJECTIONS

One objection to the argument that I am attempting to make regarding the place of
spirituality within wide reﬂective equilibrium is that the former is an ethical theory and
the latter is a meta-ethical theory. This could be said on the grounds that spirituality, in
many cases (though certainly not necessarily), involves adherence to rules of a particular
religion or belief system. By this line of argument, spirituality would be a method for
moral decision-making via adherence to a set of rules, principles, and guidelines. Wide
reﬂective equilibrium, on the other hand, is a coherence theory of morality, which (as
previously discussed) does not tell us much about how to make decisions. For this
reason, a comparison between spirituality and wide reﬂective equilibrium would not be
possible, because they are practiced on different levels.

In addition, spirituality, when rooted in a particular religion, requires (in many
cases) a strict adherence to a set of rules that therefore places those rules in a privileged
position. Wide reﬂective equilibrium, however, requires that no part of the moral agent’s
network be privileged. Therefore, the spiritual person could not be engaged in true wide
reﬂective equilibrium.

Another possible objection that could be raised against my argument is that spirituality
should not be considered in the medical context because it is so highly personal in nature.
If people have the right to believe whatever it is that they want to believe, then it seems
problematic to use the information about the beliefs of individual patients to serve as
justiﬁcation for actions that medical personnel take in particular cases. This is of even
greater concern when the actions that are taken go against the standard of care that is
usually practiced. By using the personal beliefs of a patient as justiﬁcation for the actions
taken with regard to that patient, we are just creating a system of medical care in which
anything goes. Further, if we allow spiritual considerations to be a guiding force in
decisions about end of life care, then we have no way by which to make decisions for

those patients who claim to not have spiritual convictions.

26

 

 

RESPONSES

I believe the ﬁrst objection is rooted in an unfortunate perspective of what it
means to be a spiritual person. As stated earlier, spirituality is not limited to religion.
Moreover, if one chooses to call herself a member of a particular religious group, it does
not mean that she is a limiting herself to being a rule follower. She is not committing
herself to blindly following the rules of a particular religion, rather she makes decisions
to follow or to not follow those rules based on her spiritual convictions, values, and
transcendental perspectives, in conjunction with her conception of her own identity. To
say that she is merely following rules is to accuse her of being a moral infant who has not
morally progressed beyond her Sunday school lessons.

The spiritual enterprise, instead, should be considered a meta-ethical theory much
like the enterprise of wide reﬂective equilibrium. This is because one’s sense of
spirituality will help one to determine which rules and principles to adopt, how to make
considered judgments, and how to treat others justly. That sounds remarkably like what
wide reﬂective equilibrium is helping us to do! However, spirituality goes a step further,
by giving us insight into how we should make particular decisions. People are able to
incorporate their sense of spirituality into their continual quest for a comprehensive and
coherent moral network.

In response to the second objection, I would begin by saying that even if a patient
does not consider himself be to spiritual, he still places value on some things over others.
In this way, even if the patient is not spiritual, his care still needs to be discussed with
him so that decisions can be made for him in accordance with what he values in his life.
There is no reason that those values need be spiritual in nature. For example, he may
value his autonomy and personal freedom above all else. If this is the case, then the
medical personnel involved in his care should work with him so that he can be placed in a
facility that will allow him live in his own apartment and to cook his own meals if he

desires. The medical personnel need to work with the patient as much as possible to help

27

him to demonstrate that he is able to take care of himself and therefore is well suited for
an assisted-living facility, rather than a nursing home.

Further, even though everyone may not be spiritual, there is evidence that the vast
majority of people are. But all statistics aside, even if only a minority of people consider
themselves to be spiritual, those people still need consideration. At minimum, medical
personnel need to recognize that there is something invisible out there that needs to be
considered. There is a dimension to some people’s lives that is highly personal and
intimate, but that helps to make them who they are. By not considering the spiritual
convictions, values, and transcendental perspectives of people who care about such
things, medical personnel would be neglecting an essential part of who those people are.
Patients simply cannot receive optimal treatment if what it is that is important to them is
ignored. Therefore, it must be considered when helping patients to make decisions about

their end of life care.

28

THE THEORY IN PRACTICE

In thinking about what it means to incorporate wide reﬂective equilibrium and
spirituality in end of life decision-making, it is useful to reconsider the case presented at
the beginning of this paper. Recall that an 87-year-old woman, at some point in her
medical treatment, was faced with the decision to give into her fear of death and continue
treatment, or continue to put the best interest of her 55-year-old daughter before her own
and stop treatment, thus giving her freedom from the burden of being her mother’s
caregiver. In this situation, the patient had to give up one of the two convictions that she
had held to that point without a conﬂict.

In considering the role of the medical personnel in helping this woman to come to
a decision about the continuation or termination of her treatment, it is useful to ﬁrst
consider the way that the woman could be helped by using wide reﬂective equilibrium.
In relaying information about treatment and non-treatment options to the patient, the
medical personnel could have asked the woman to identify reasons for continuing
treatment and reasons for stopping treatment. Through this discussion and analysis (and
perhaps through conversation with the daughter) it should have become apparent to the
medical personnel that the woman was torn between her two convictions. The medical
personnel could then work to help the woman to make a decision between the two
convictions and therefore make a decision about the termination or continuation of her
treatment.

In helping the woman to make a decision about her treatment, medical personnel
can ask the woman to consider hypothetical situations in which she would have to face
the same kind of conﬂict. For example, the woman could be asked to consider a situation
in which she would be put in a position to have to sacriﬁce her life to spare her
daughter’s life. In this case, the woman would probably say that she would have

overcome her fear of death to save the life of her daughter. She would have been able to

29

overcome this fear because she would have placed the value of the life of her daughter
above the value of her own life.

After thinking about this kind of hypothetical situation (and possibly others)
medical personnel could ask the woman about her spiritual convictions and
transcendental values. She could be asked what she believed God, or the cosmos, would
want her to do. She could be encouraged to medicate, pray, or reﬂect upon the weighing
of the conﬂicting convictions. At no point should the medical personnel tell the woman
which decision to make. Rather, they should make themselves available to speak with
her as much as she would like and to provide her with any information about her
treatment options which would help in her decision-making process.

There are, of course, ways that the conversation can go wrong. Just having a
conversation with a patient is not enough, because the content of the conversation and the
manner in which the conversation is approached matters. There are ways that
conversation can make things worse for the patient. Medical personnel must be sensitive
to the needs of the patient and not force the patient to discuss issues that she is not ready
to discuss. The conversation must be directed by the patient, with the medical personnel
being sensitive to what the patient is comfortable discussing. The patient cannot be
forced into conversation. There is much that can be said about the ways that medical
personnel should approach and carry out conversation with patients and their families,
but that discussion is beyond the scope of this exploration. It is, however, important to
keep in mind that not all conversation will be of beneﬁt to the patient.

Ultimately, treatment decisions are in the hands of the patient. No matter what
she decides to do, the medical personnel involved in her care can feel good about the fact
that whatever decision she ultimately arrives at is one that came through careful
consideration. By giving the patient the necessary amount of time to make a good
decision and by remaining available to help her when necessary, the medical personnel

can rest assured that the decision that was made was in the best interest of the patient.

30

CONCLUSION
It has been my goal to demonstrate that spirituality has a place in wide reﬂective
equilibrium. Moreover, I believe that I have shown that they may in fact be the same in
some respects. Both are tools for acting as moral agents, but they also help us to have
and develop an identity. Both address conﬂicts and are able to progress because of
decisions made about those conﬂicts. Both seek unity. Both require work on the part of
the individual. Most of all, spirituality and wide reﬂective equilibrium help us to live and

function as moral agents in an increasingly complex and plural society.

31

WORKS CITED

Brenner, Verna Carson. “Spirituality Described” Spintual_Dimensioa§ of Nursing
Practice. W.B. Saunders Co., 1989: 6-13.

Clinbell, Howard. Baaic Types of Pastoral Care and Counselingszesources for the
Minisﬂ of Healing and Growth. Abingdon Press: Nashville. 1984.

Daniels, Norman. “ Wide reﬂective equilibrium and theory acceptance in ethics.” As
found in Justice and Justiﬁcation: Reﬂective equilibrium in pragtice. New York:
Cambridge University Press. 1996. pg. 22.

Hardwig, John. “Is there a duty to die?” Hastings Center Report 27, no. 2 (1997): 34-42.

Hufford, David. Second Annual Foglio Conference on Spirituality and Medicine at
Michigan State University on October 6, 2000. Keynote address.

F oglio, Jake. Lecture at the Second Annual Foglio Conference on Spirituality and
Medicine. Michigan State University, October 6, 2000.

F oglio, Jake. “Spirituality and Medicine,” in “Spirituality: A Vital Component of Well
Being.” Coursepack for HM 548, Michigan State University College of Human
Medicine, Spring 2001, 26-29.

Robert Wuthnow. After Hegen: Spirituality in America Since the 1950’s. University of
California Press, Berkley. 1998. Chapter 1.

32