 
SIMPLY ASK

A Guide to Religious Sensitivity for Healthcare Professionals

By Gerrie Lubbe

gerrie@lubbe.co.za

Published by Michel Clasquin-Johnson Publications at Smashwords

On behalf of the Desmond Tutu Diversity Trust

PO Box 1964, Honeydew, 2040

diversitysa@telkomsa.net

http//www.desmondtutudiversitytrust.org.za

Cover Design by Claire Holton

Edited for electronic distribution by Michel Clasquin-Johnson

Copyright 2013 Gerrie Lubbe

ISBN: 9781301665235

1st Smashwords Edition, License Notes

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TABLE OF CONTENTS

Acknowledgements

Foreword

Introduction

.. Spirituality and Healthcare

.. Defining Spirituality

.. Spirituality and Religion

.. Increasing Interest

.. Influences of Religion and Spirituality

.. Role of the Health Professional

AFRICAN RELIGION

.. Anecdotes

.. Introduction

.. Basic Beliefs

.. African Religion in South Africa

.. Health and Healing

.... Health and Harmony

.... Pain

.... Biomedical Approach

.... Diviners

.... Understanding of death

.. Practical Matters

.... Religious Affiliation

.... Rituals

.... The Hospital: Haven or Haze?

.... The Inadequacy of a Biomedical Approach

.. Additional Information

THE BAHÁ'Í FAITH

.. Anecdote

.. Introduction

.. Basic Beliefs

.. The Bahá'í Faith in South Africa

.. Health and Healing

.... Alcohol, Drugs and Tobacco

.... Diet

.... Donation of Organs and Blood

.... Circumcision

.... Prolongation of Life

.... Death

BUDDHISM

.. Anecdote

.. Introduction

.. Basic Beliefs

.. Buddhism in South Africa

.. Health and Healing

.... Dietary Requirements

.... Hygiene

.... Religious Practices

.... Death and Dying

CHRISTIANITY

.. Anecdote

.. Introduction

.. Basic Beliefs

.. Christianity in South Africa

.. Health and Healing

.... Pastoral Care

.... Mass or Eucharist

.... Dietary requirements

.... Death

.. Excursus: Jehovah's Witness

HINDUISM

.. Anecdote

.. Introduction

.. Basic Beliefs

.. Hinduism in South Africa

.. Health and Healing

.... Death

.... Ritual Purification

.... Food Restrictions

.... Fasting

.... Modesty

.... Worship

ISLAM

.. Anecdote

.. Introduction

.. Basic Beliefs

.. Islam in South Africa

.. Health and Healing

.... Prayer and Ritual Purification

.... Dietary Requirements

.... Fasting

.... Muslim Festivals

.... Modesty

.... Death

JUDAISM

.. Anecdote

.. Introduction

.. Basic Beliefs

.. Judaism in South Africa

.. Health and Healing

.... Circumcision

.... Sanctity of Life

.... The Here and Now

.... Food Restrictions

.... Visitors

.... Death

Conclusion

Epilogue

Annexure: Definitions

Bibliography

About the Book, the Author and the Trust

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**Acknowledgements**

I would sincerely like to thank TrustAfrica for their generous sponsorship which enabled the Desmond Tutu Diversity Trust to publish the original, paperback version of this book and to embark on a training programme on religious sensitivity for healthcare professionals. I would like to particularly acknowledge Dr. Akwasi Aidoo (Executive Director) and Ms. Chantal Uwimana (Programme Director) for their enthusiasm and support of this project from the very beginning.

The on-going support of our patron, Archbishop Desmond Tutu is vitally important to us and we are grateful that he graciously agreed to lend his name to our cause. I also want to thank him for writing the Foreword.

To the Board of Trustees of the Desmond Tutu Diversity Trust: my sincere thanks for their interest and support. I am grateful for their constructive comments as they read different chapters of the book and I acknowledge the help and support of Michel Clasquin-Johnson, Wendy Howson, Ian Mann, Sean Moodley, Shohreh Rawhani, Ujala Satgoor, Shamshad Sayed and Elijah Wachira.

I would also like to acknowledge the time, effort and advice contributed by Mrs Vyvyan Bean, Prof.Yousuf Dadoo, Prof. Paul Gundani, Rabbi Pinhas Zekry, Prof. Celia Kourie, Prof. Johannes Kritzinger, Dr. Paul Manci, Dr. Victor Molobi, Mrs. Ellen Molobi, Mrs Lydia Monareng and Dr. Matome Rathete.

The main body of this book comes from a chapter I contributed to a Juta and Co Ltd publication which was published in 2004 and was entitled Cultural Issues in Health and Health Care: A Resource Book for Southern Africa, with Adele Tjale and Louise de Villiers as editors. The chapter I contributed was "Health Care for People of Different Faiths" and I wish to thank Juta for their permission to use my contribution as foundation for this book.

In this first electronic edition I would like to express my appreciation for the positive way in which Simply Ask! was received over a wide spectrum. I trust that it will continue to convey a message of understanding and respect wherever healthcare is provided and received. I am particularly grateful to my friend Prof. Detlef Prozesky who delivered such a meaningful address when this publication was promoted in Johannesburg in 2008. I also thank him for his permission to include his address in this edition, knowing that it will enhance the quality of Simply Ask!

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**Foreword**

This booklet aims to sensitize and equip healthcare practitioners with knowledge about the religious and spiritual needs of their clients.

We are probably at our most vulnerable when we need healthcare. It is then that we want to draw on our spiritual resources. When healthcare professionals show sensitivity for the spiritual and religious dimensions of their patients, the message conveyed is that patients are seen and treated as whole people, not simply as "cases".

Due to ignorance of religious beliefs and traditions of others, unintentional mistrust, misunderstanding and offence are caused while providing healthcare. As a guide within the South African context, this booklet plays a role in eliminating these societal ills and as such, it contributes to the struggle against that which conspires to separate and alienate us from one another.

The author and the Desmond Tutu Diversity Trust should be commended for this publication.

Archbishop Desmond Mpilo Tutu

June 2008

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**Introduction**

South Africa is, and always has been, a country of religious diversity. However, due to the previous dispensation of socio-political segregation, multiplicities of religious tradition has not been the experience of many people in the country. Recently, with the integration of residential areas, education and health service, more and more South Africans have come to encounter people of different religious and spiritual beliefs.

The arrival of a democratic dispensation in South Africa's political and societal life brought with it many challenges. Amongst these challengers was the "sudden presence" of people of different faiths in all public hospitals and health care centres. Segregated health services, which were in accordance with the policy of Separate Development, better known as Apartheid, meant that health care workers mainly encountered Christians and Jews in "white" hospitals, whereas those working in "non-white" facilities, would encounter Christians, African Traditionalists, Hindus and Muslims.

With the integration of health facilities during the early nineties, staff had to deal with patients who held religious beliefs and who performed religious practices that they were totally foreign to them. The realisation that all people are entitled to be treated with respect and dignity, including their religious beliefs, prompted officials and members of the South African Nursing Association and its various regions, as well as staff at training colleges for nurses, to seek advice and information from inter-faith organisations.

For a number of years, the author contemplated answering the call for assistance by health care professionals because he had been involved in inter-faith dialogue and cooperation for many years and knew there was a dire need for information. The Desmond Tutu Diversity Trust promotes understanding and appreciation of all aspects of cultural diversity in South Africa and became a suitable context for such a publication. In this booklet, seven religious traditions, prevalent in South Africa are discussed, namely: African Religion, Bahá'í, Buddhism, Christianity, Hinduism, Islam and Judaism. In the case of each tradition, basic explanations of its main tenets are given, then attitudes towards illness and healthcare are discussed and finally, practical matters are raised where appropriate.

Healthcare in South Africa is characterised by a highly professional attitude. Behind the repeated calls for sound information regarding the practices and beliefs of different faiths received from this quarter, was a sincere desire to render high quality of care and service. The need to be informed about the rituals and beliefs of various religious traditions, certainly echo the spirit of the old adage: "to be forewarned is to be forearmed". Even a basic understanding of the different religious beliefs and practices will help minimise embarrassing situations and avoid being unintentionally offensive.

Although it is quite likely that different religious practices may contain common elements, the details which define the religious practice, will certainly differ from one religion to another. So, we cannot assume that all patients have the same religious or spiritual requirements and it is essential that healthcare professionals are provided with a basic knowledge of the main religious traditions in South Africa. It is also hoped that such knowledge will find its way into the curricula of training institutions.

We cannot expect healthcare professionals to become experts on the details of the seven most prominent religious traditions in this country because their primary focus is always on the provision of healthcare. Informative literature, including this publication, will have limited effect as far as an "expert" knowledge of different religious practices is concerned. But what will have more impact than having the facts at hand? Having the correct attitude!

Simply Ask attempts to instil a sense of sensitivity and tolerance regarding the religious or spiritual needs of patients. Over the arrogant assumption of knowing it all, the attitude of asking and learning will be of greater service. In this way, healthcare professionals will have a positive impact on situations that could be disconcerting and unpleasant.

When Babe, the little piglet in the movie of the same name, is entered by his owner into the sheepdog trials, he initially has problems gaining the cooperation of the sheep. After consulting a senior ewe on how to win their trust, she tells him to simply ask nicely! He follows her instruction and the sheep perform flawlessly on the day of the trials.

It is our wish that this booklet becomes a guide to all healthcare professionals and if we learn from Babe, and observe the golden rule of simply asking when we do not know, we'll go a long way in becoming sensitive to the spiritual needs of all recipients of healthcare.

_Spirituality and Healthcare_

Before we look at the details of practising a particular faith, or even not practicing one, it is necessary to entertain the question of whether there is a connection between spirituality and healthcare.

_Defining Spirituality_

In starting our discussion, we must define the concept spirituality and to understand the relationship between spirituality and religion. In 2000 a report entitled "Faces of Ageing" was published by the Wesley Mission of the Uniting Church in Sydney, Australia. According to this report, spirituality is described as a particular world view, a way of looking at and responding to the world of experience and other people, which generates meaning and purpose for living. The report further stresses that every person has "spirituality", not just "religious" people. While many people express their spirituality through organized religion of some form, there are even more who do not.

Siroj Sorajjakool (2006:9) defines spirituality as the coexistence of the inner realization of something bigger than us. Russell D'Souza (2007) states that; although spirituality is a concept globally acknowledged, there is no consensus on how to define it. According to him, spirituality can encompass belief in a higher being, the search for meaning, and a sense of purpose and connectedness.

In summarizing the above, spirituality signifies the desire to make sense of the events taking place in one's life. While others may subscribe to such a statement, they may add that it also involves understanding the fact that there is a bigger reality than the reality in which we find ourselves and this brings us to the relationship between spirituality and religion.

_Spirituality and Religion_

D'Souza (2006:11) states that although religiosity and spirituality are not synonymous, there can be a wide overlap between them and the inner ontological drive to make sense and make meaning of our existence. When turning to the meaning of religion, he calls it a belief system that emerges from that inner longing for meaning (2006: 11).

In referring to the inner longing for meaning which he ascribes to spirituality, Sorajjakool sees religion as a belief system that emerges from that inner longing. Harold G Koenig (2001), while conceding that religiosity and spirituality have various definitions, gives a description of the function of both these concepts: patients' religious needs may include making peace in one's relationship with God and with others in one's life, readying oneself for the afterlife, and attending to the ritual requirements of one's religion.

Patients' spiritual needs, often described as more general than religious needs, may include the problem of finding meaning and a sense of control in one's life, forgiving oneself and others, obtaining forgiveness, reflecting on the course of one's life and one's accomplishments, and saying goodbye to loved ones.

_Increasing Interest_

It seems that until recently, relatively little attention was paid in academia to the role of spirituality in the healing process but this has changed during the past one and a half decades. When commenting on the Wesleyan Mission's report on "The Faces of Ageing", the Federal Representative of the Christian Science Committee on Publication reported that since 1990, almost 1500 research studies, research reviews, articles and clinical trials were published on the connection between spirituality or religion to medicine and health \- a figure equal to the total of all pieces published prior to 1990. It is clear that the relationship between spirituality and healing and medicine is rapidly becoming a major area of clinical research. (Wesley Mission Uniting Church, Sydney 2000.)

Russell D'Souza (2007) believes that, on the basis of this renewed interest, healthcare professionals should be required to learn about the ways in which religion and culture can influence a patient's needs. He further stresses the importance of such knowledge:

By keeping patients' beliefs, spiritual/religious needs and supports separate from their care, we are potentially ignoring an important element that may be at the core of patients' coping and support systems and may be integral to their wellbeing and recover.

_Influences of Religion and Spirituality_

Before we consider some studies regarding the influence of religion and spirituality on health, it may be good to consider reasons why patients resort to religion in times of illness. The following are the most commonly acknowledged reasons:

1. Religious beliefs enhance the ability to cope with illness.

2. Religion acts as a painkiller to reduce physical and mental pain.

3. Religious commitment protects against depression and suicide.

4. Religion promotes health by adding social or psychological support.

5. Religion contributes to a positive attitude and a sense of determination in medical rehabilitation.

Rebecca Rosen Lum (2007) reports that numerous studies show common links between faith and outlook, faith and well-being and faith and healing. According to her, scientists at such prestigious institutions as California Pacific Medical Centre in San Francisco, Duke University in North Carolina, and the George Washington University Institute for Spirituality and Health are exploring the relationship of prayer and faith to healing. According to D'Souza (2007), hospital officials have long left patients' spiritual needs in the hands of chaplains, but they are increasingly reaching out to faith communities. Brick Johnstone, a health psychologist at the University of Missouri said: Religion is infrequently discussed in rehabilitation settings and is rarely investigated in rehabilitation research. To better meet the needs of persons with disabilities, this needs to change. To inquire about a patient's religious beliefs is no different than inquiring about their sexual, psychological, substance use and legal histories.

Dr. Harold G. Koenig, co-director of the Centre for Spirituality, Theology, and Health at Duke University Medical Centre has, together with colleagues, conducted several studies on the influence of religious beliefs on health and well-being. Koenig suggest that high intrinsic religiousness predicts more rapid remission in depression, especially in patients whose physical function is not improving. In a meta-analysis of more than 850 studies, Koenig and Peterson (1998) examined the relationship between religious involvement and various aspects of mental health and they found that in the majority of studies people experienced better mental health and adapted more successfully to stress when they were religious.

A further analysis of 350 studies, conducted in 2000, found that religious people are physically healthier, lead healthier lifestyles and require fewer health services. (Koenig 2000/1) In a study concerning religiosity and the elderly, Koenig also found that participation in, and an affiliation to, a religious community reduced the use of hospital services.

So, there seems to be an undeniable link between religiosity, spirituality and well-being but these facts do not mean that religious practices should replace psychiatric and other medical treatments.

_Role of the Health Professional_

Whilst spiritual care appears to be taught at many medical schools in the USA, D'Souza warns (2007) that doctors and clinicians should not "prescribe" religious beliefs or activities or impose their religious or spiritual beliefs on patients. He stresses that the task of in-depth spiritual counselling of patients is best done by trained clergy. Whilst there are limits when it comes to the involvement of healthcare workers in spiritual care, there is no doubt that such professionals inevitably become healers through the caring relationships they form with their patients. A consensus panel of the American College of Physicians suggests four simple questions that physicians could ask patients. (Lo, Quill and Tulsky: 1999)

* Is faith (religion, spirituality) important to you?

* Has faith been important to you at other times in your life?

* Do you have someone to talk to about religious matters?

* Would you like to explore religious or spiritual matters with someone?

These questions not only demonstrate that a physician is aware of the importance of spirituality but also extends an invitation to make use of professional assistance in this regard.

To understand this book as merely reporting on interesting practices to be associated with people who hold different beliefs, would be to entirely miss its essential message. Hopefully, the importance of developing religious sensitivity has been made evident. When you develop religious sensitivity you create space, even sacred space, for individuals who are attempting to make sense of the events that have come into play in their lives. Besides allowing patients to practice their religious beliefs while in hospital, healthcare institutions would do well to offer a service that permits people access to comforting and understanding caregivers or counsellors.

One of the most important gifts a caregiver can bring is an empty self without words or actions. Simple presence can communicate something much more beneficial than careful selection of words or well-strategized deeds (Sorajjakool 2006)

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**AFRICAN RELIGION**

**Anecdotes**

Khanyile (1998:72) reported the following incidents experienced by African nurses from other cultural backgrounds while working in a hospital in KZN. These incidents indicate a lack of cultural knowledge:

1. Patients in a male ward refused to eat the food given to them by a couple of non-Zulu nurses. According to them, the nurses did not give the food to them "properly" because they did not bow down. Bowing by Zulu females is a sign of showing respect towards males. When commenting on this incident, one of the nurses remarked to the researcher: "I was shocked to learn that Zulu patients expect females to bow down." Another one remarked: "I was surprised because in my culture I am not supposed to kneel or bow down."

2. A female patient removed the sterile dressing that covered the wound on her head in an attempt to cover her head. It was during the visiting hour and her mother-in-law approached her. According to the Zulu custom, married women are supposed to cover their heads with a scarf at all times as a sign of respect. The non-Zulu nurse who observed this, remarked: "I was shocked to see what she did. It was a learning experience for me because I did not know that Zulu females are supposed to keep their heads covered."

3. A non-Zulu nurse was on duty when she found a Zulu patient delivering her baby on the floor. In accordance with Zulu custom, a woman is expected to kneel down when giving birth. This amazed the nurse.

**Introduction**

African Religion is characterised by a variety of concepts and practices but there is a sufficient number of common features shared in sub-Saharan Africa to distinguish this religious orientation from other world religions.

**Basic Beliefs**

Belief in a Supreme Being

Throughout Africa there is a belief in a Supreme Being. One or more names describe him either in terms of his activities or his place of abode. This Supreme Being created and set the world in motion and God is, above all else, the creator of all things and as such the basis of all that is.

An intermediary is used when the Divine needs to be addressed. These intermediaries are treated with respect, since respect of the intermediary is understood as respect of God. These intermediaries are the ancestral spirits and this religious arrangement mirrors general cultural patterns of interaction between living members of the community as well. The general view is that God is never far away from an African's thoughts or perceptions of the world.

Belief in Ancestral Spirits

Some traditionalists suggest that only those who have married and produced offspring can become ancestors when they die. Those who have not married and had children rapidly fade away and are forgotten. However, these views are often contested. The relationship which exists between the living members of a family and those who have died is a reciprocal one. While the ancestors enjoy the respect and honour of the living by being included and remembered in family functions and in decision-making processes, the living family members also rely on the ancestors for protection and prosperity. Although the ancestors are remembered, and at times even feared, they are not are worshipped. However, they are asked for help and protection.

Belief in the Sanctity of a Unified Community

From birth, an African is guided and trained with a purpose of realising a full and complete life. Nonetheless, in the process, Africans are constantly reminded that they are part of a community. Since life is communal, the individual almost automatically becomes integrated into a network of mutual relations within the community. Far from being looked upon as a sacrifice of individual freedom, this existence-in-community is accepted as indispensable for security and wholeness.

**African Religion in South Africa**

African Religion is the oldest form of religion in South Africa and can be traced back to the religious practices of the San and the Khoi. Also, vivid proof of the continuing influence of African religious views is found in the process of cross-fertilization between the African ethos and Christianity in South Africa. The result of this cross-fertilization is the emergence and growth of the African Indigenous Churches where many Africans have found a spiritual home. It is not possible to estimate the number of adherents of African Religion in South Africa but what is certain is that, next to Christianity, African Religion has the biggest number of adherents in our country. Unlike elsewhere on the continent; Africa Religion in South Africa holds a lower profile when compared to Christianity. The previous political dispensation was responsible for misrepresenting, marginalising and even suppressing African Religion.

**Health and Healing**

_Health and Harmony_

In Africa, good health means much more than just a healthy body. Besides a physically healthy body, "good health" also includes a harmonious, coordinated universe. This is true for African people throughout sub-Saharan Africa. Health, balance, harmony, order, and continuity are keywords that describe "good health". Not only does it describe a desirable present condition for individuals and the community, but also represent the goal towards which Africans strive. These ideals need to be maintained, not only within the visible community, but also in relation to the invisible community which are viewed as spiritual powers.

So, when people are happy and healthy, when livestock is increasing and prosperity abounds, harmony is experienced in Africa and when Africans see that their ancestors are happy and at peace, all is protected and secured. Conversely, when natural disasters, misfortune or sickness strikes, some kind of intervention and communication with ancestors is naturally sought. The purpose of such communication will be to call for attention to something that needs to be done to restore security and prosperity to a person, a family or an entire community. It could also remind their living counterparts of some ritual that needs to be done for the wellbeing of the ancestors.

In viewing illness and the causes for it, it is necessary to remember that ancestors are spirits and as such they cannot meaningfully engage the living whose experience largely depends on sensed and physical realities. Therefore, for the ancestors to express themselves to the living, some kind of embodiment becomes necessary. Because there are no "spare" bodies readily available, they inhabit one. In most cases, when ancestral spirits inhabit a body, it is generally not with the aim of hurting the person concerned. They want to find out who is calling for help, and how to rectify the problem. The ancestors who occupy the body live off the body's vital strength and so the individual's vitality is depleted and sickness could result.

_Pain_

Within the African context, pain is not predominantly physical or individualistic, but also has strong psychological and social undertones. Consequent to the African worldview that says "nothing in life just happens", natural events and coincidences need to be separated from engagements by the ancestors. The African world view insists that "to be" is to communicate and to constantly influence mutually. So, it is important to search for the hidden meaning and possible intentions of a particular event or incident in order to pick up the messages and to interpret their subtle meanings. Therefore, not all sickness and disease should be interpreted as a medical problem. If an ailment is perceived to be a message rather than a sickness, it may be meaningful for the patient to be assisted in giving an appropriate response. Of course, pain should be relieved, so pain killers can be administered but only as a temporary measure.

_Biomedical Approach_

African people perceive Western medicine as a means of treating symptoms, but they also believe that unless the cause of an illness is ascertained the treatment is superficial. They believe that the cause of illness can be found in the initial and then continued disruption of harmony, and these disruptions then generate stress. That which disrupts the flow of life, either of an individual or the group as a whole, is considered evil, i.e. killing someone. This disruption must be avoided at all costs. If not, the cause must be ascertained and remedied so that the vital life force can be restored. The process of continuously defending against disrupting the life force binds the community and keeps it intact.

To avoid making a massive "western" vs. "African" dichotomy, we speak of the "bio-medical" approach or model, rather than "western medicine". Modernisation is proceeding quickly in African cities and now there are many Africans who are health care professionals and have adopted the biomedical approach as the best (or only) model. And conversely, many Western people practise alternative medicine.

_Diviners_

In African society, certain people experience the call from their ancestors to undergo training to become African (or traditional African) healers. Those chosen and trained are called diviners (not "witchdoctors") and they specialise in diagnosing the causes of illness, they prescribe the ritual solutions to the disturbance, they predict the outcome of processes and they control the spiritual forces involved. Diviners are consulted when needed and when a person is in the grips of fear and anxiety. Some of these fears include: a fear of evil spirits and malicious persons (known as witches or sorcerers) who use medicine to harm and destroy, a fear of offending the ancestors and fear of losing vital life force. In addition, anxieties are triggered by natural disasters, drought, infertility, and increasingly, by the complexities encountered by those who are living in urban areas.

Sickness and pain are often experienced when relationships are disturbed or when problems are encountered in the socio-economic and political spheres. This truth can be seen by an increase in the number of Africans who consult diviners and traditional healers. This happens when some misfortune or unusual event affects their lives and they consult diviners for diagnostically oriented interpretation of events. The diviner will propose an action to address the problem, either in terms of medication or a ritual that would involve an animal, such as a fowl, a goat or a cow. It may be wise for a hospital to reserve one or more cubicles for consultation with an approved traditional healer. Although nobody should be forced to consult an African or Western medical practitioner, mutual consultation between these two professions may be very beneficial for all parties involved.

_Understanding of death_

Death is an accepted reality and is not feared because death does not end a life. Life is lived in a series of events and death is one of those events. Therefore, death is not seen as the end to life, neither is it believed as a complete annihilation of the person. Africans believe that when someone dies, he or she moves on to join the departed. The dead do not vanish but enter a state of collective immortality, so death is not the last word.

Although death is an accepted reality, it is the disruptive nature of this phenomenon to family and communal harmony that brings anxiety and misery. Death is most unwanted when it comes before one has accomplished the so-called divine ordinance. A man who dies before he finishes paying lobola, will for instance, summon close relatives to pay it for him. A person who sees death coming and has not reconciled with others, will summon those with whom she or he must be reconciled. Some may take a long time to die and use their time to confess and explain their actions and thoughts. This is known as ukumpompa, or ukuzibula.

Another reason why African people fear death is because they believe that some deaths are not Divine Will. For example; when a person dies young, especially when things are going well, they are doing well at school, are successful in business etc., there is a belief that their soul or spirit was stolen (ukuthwebula) by witches who want to use it for evil purposes. Africans believe that after the funeral, the witches go by night and exhume the body and resurrect it.

**Practical Matters**

_Religious Affiliation_

It's rare that s/he will openly declare that they are a practitioner of African Religion. They are more likely to say they are a member of a Christian church or denomination. Nevertheless, this should not be viewed as deception. The reasons why an African will not readily announce his participation in African Religion is that, historically, many schools and hospitals in rural areas were run by church related organizations and it was thus regarded as "civilised" or proper to belong to a church. Another reason is that they might be committed Christians and also practising members of African Religion. So, it is fair to assume that the majority of Africans have some kind of link to the church, whether out of choice, or out of force.

_Rituals_

The performance of rituals plays a major role in the life of both the individual and the community. Rituals strongly come to the fore during rites of passage; such as birth, initiation, weddings and funerals and when the ancestors are revered and their blessings and benevolence requested. Rituals performed during these events are also often seen as cultural rather than religious. This fact makes it possible for an African who belongs to a Christian church also able to turn to traditional practices and thus holds a double allegiance.

_The Hospital: Haven or Haze?_

Like many of us, Africans are scared of going to hospital, but for Africans the reasons are different. A hospital is seen as an unnatural place because patients are away from the guiding influence and tender care of their relatives. In hospital, the ancestors are still aware of their whereabouts but if not, the patient could be rendered outside the ancestors' protective reach. Ancestors are often credited with the healing process, so many believe that a person might get the right medicine for the illness but if the ancestors do not constitute part of the healing process, the person might not be healed. This explains the reason why Africans want to take their ancestors with them when they go to hospital.

There is a popular belief that being hospitalised means death and in the African mind, serious religious concerns are linked to the notoriety of hospital as a place of death. According to Austine Okwu, (1978:5) in an African cosmology a person is understood to have died when the spirit separates from the material body. Under normal circumstances, this should only happen because of the physical deterioration of the body resulting from old age. It is "the rite of passage par excellence", reserved only for the elderly who have gone through life's other crisis-rites. Deaths of young people, or women dying during pregnancy or childbirth, homicide, suicide and all deaths due to accidents or anything outside normal ageing, are regarded as contrary to cosmic order. Okwu refers to such untimely deaths as "jumping the queue of dying".

These people are not given the same funeral rites as are given to the elderly, nor are they included, remembered or mentioned in the litany of ancestors. The implication of this is that a patient who dies in hospital, s/he runs the risk of being disqualified as a potential ancestor, and thus falls into total oblivion. The necessity for healthcare professionals to understand this is self evident and of paramount importance when treating patients.

If at all possible, visiting hours should be extended because of the sanctified unity of community in traditional African worldview. Also, provided that the patient's condition allows it, as many family members as possible should be allowed to visit because in a worldview where people's lives are intertwined with the vitality of others, it may be considered prudent to afford the sick person as many life sources as possible.

_The Inadequacy of a Biomedical Approach_

In Western society, disease is seen as a biological phenomenon and medicine is regarded as the principal response to it. In an African context, disease is often seen as caused by events that have disrupted unity and harmony. This in turn brings stress both to the group and to its individual members.

Many African people do not expect to be healed through biomedical procedures alone. Healing has to be associated with divinity and this is achieved in two ways;

* By means of rituals and sacrifices and

* by means of traditional medicines.

Another major difference between individualistic biomedical and communal African therapies is that in the western practice of medicine it is generally viewed as pre-formulated and impersonal in dispensation. In contrast, traditional healing practices are tailor-made, so to speak. The rituals, the healing and the preventative prescriptions are designed to suit the individual's special relationships and circumstances.

Consequently, such therapies are exclusively private and viewed with awe of, and respect for, the ancestral spirits involved. Healthcare professionals should be aware of this fact when obtaining a medical history. Entrance into the realm of what might not only be private but also sacred must be taken into account. Obtaining said information should be handled with great sensitivity and the information received must be held with care and respect.

In cases of serious illness or where surgery is necessary, rituals aimed at requesting ancestral protection for survival and the retention of life are performed. Obviously, it would be preferable to perform such rituals at home, even if the patient has already been admitted to hospital. Healthcare professionals should try to understand that a patient, if at all physically possible, would want to return home prior to a major operation. If the physical condition of the patient does not allow this, then relatives, and traditional healers, should be allowed to perform the necessary rituals at the patient's hospital bed.

In some cases, families would want to perform rituals at the bed of a relative who has died. The aim of such rituals is to remove the spirit of the deceased from the actual bed in order to prevent it from getting confused. For instance, when a Zulu patient dies in hospital, the family usually goes to the bed where the patient slept and then calls the dead by name and tells him/her that they have come to fetch him/her and want to take him/her home.

Since this request may come some days after the death has occurred, it may well be that that particular bed has already been filled. Such a situation will require skilful negotiations from the side of the staff and normally some kind of compromise can be reached with the family, such as performing the ritual at the door of the ward or some similar arrangement. This is a very important ritual and if at all possible, its performance by the family should be permitted.

Where it is necessary to supplement biomedical drugs with traditional medicine, healthcare professionals must be aware of the ingredients of the potion, as well as the method of its application. A potion would normally consist of holy water or herbs or a combination of the two. In the case of a terminally ill patient, potions may be used to cleanse or purify the soul of a patient and to ensure a peaceful death. Healthcare professionals should, at all times, work with both patient and family to decide when traditional medicine could be applied. Where the medicinal properties of certain herbs clash with the medication a patient receives, the family should be tactfully requested to refrain from using it. Where incisions are made by a traditional healer to insert traditional medicine, the process as well as any instrument used, should be overseen by healthcare professionals.

**Additional Information**

In most African cultures, an old male will not allow a nurse who is the same age of his daughter to bath him because he feels she is like his child and that it is improper for her to see his private parts.

A Zulu patient with very high blood pressure would want go home where he can slaughter a cow as he might feel that the ancestors are complaining and have shown it by making him sick and so he should slaughter a cow to beg for mercy.

Xhosa men would prefer not to be circumcised under anaesthetic because they need to prove that they are man enough to withstand the pain and suffering.

When pregnant Venda women are due but have not yet arrived at the hospital, they are given a small stone to hold in their hands until they get to the hospital. This symbolizes a promise that she will not give birth until she gets to the hospital.

When ill, African traditional healers will not go to hospital unless they feel it is beyond their control and, if possible, will only allow male nurses to treat them.

African traditionalists want to burn African herbs in the ward because they believe the herbs will remove evil spirits that may be in the ward. African traditionalists would also prefer to drink their traditional herbs in conjunction with the conventional medicine prescribed by the doctor. Traditionalists mix their bath water with herbs as part of the healing process when bathing.

******

THE BAHÁ'Í FAITH

**Anecdote**

The lady behind the counter looked at the completed form that David put in front of her.

"Ryan, David Russell", she read and consulted a list next to her then looked at David.

"Patient of Dr Jankowitz? Right knee?" she asked.

"That's right", said David.

She read further down the form and inserted a code at each item.

"It says here under religion... Baha'i, is there such a religion?"

"Yes, indeed. There are more than five million adherents of the Baha'i faith worldwide."

"Well, we have no code for it". She frowned and turned and asked her supervisor to come help her.

"What's the matter, Sally?"her supervisor asked.

"Sir, this young man tells me that he belongs to the Baha'i faith. My problem is that there's no code for such a faith and I have never heard of it before".

"Well, neither have I! What kind of faith is it, sir? Who do you believe in?" asks the supervisor.

"Well... we believe in God and our prophet is Baha'u'llah."

Before David got a chance to complete his sentence the supervisor interrupted.

"Baha'u'llah, but then you're a Muslim. You believe in Allah".

"No, sir", David said firmly, "I am not Muslim, I am a Baha'i."

"Well, aren't you perhaps Buddhist or something like that?" Sally tries to fit David into a religion that is represented on the form.

David shakes his head. At this point, a friendly young lady who is being admitted at the next desk smiles at the threesome.

"Excuse me, I'm Jennifer. I overheard your conversation. I am doing religious studies at varsity and there is definitely a religion called the Baha'i faith. In fact, I think it is one of the fastest growing faiths in the world".

David smiles gratefully at her.

"Oh... The only problem is that our system does not have a code for it. Do you have like a minister or a priest or something?"

"Well... there is the National Spiritual Assembly of Baha'is in South Africa that runs our affairs".

"Okay, please ask this assembly to write a letter to us and explain what the Baha'i faith is. We can then get it on to our system and create a code for it"

"With pleasure," said David, "as soon as I am out of hospital."

**Introduction**

Founded more than one and a half centuries ago, the Bahá'í faith is the youngest of the world's independent religions. They believe that Baha'u'llah was the messenger of God for this age, the age of humanity's maturity, a time anticipated in all the scriptural traditions of humanity's past. The driving force behind the enlightening of human nature, has, according to Baha'u'llah, been accomplished by the interventions of the Divine. It is believed that through the Divine's influence, the moral and spiritual faculties of humanity were gradually developed and the advancement of civilization was made possible.

**Basic Beliefs**

The essential message of Baha'u'llah is one of unity. Baha'u'llah declared that humanity has collectively come of age at this time. The distinguishing feature of this social evolution is that humans are recognising their own oneness and that the earth is their common homeland. The three basic tenets of the Bahá'í faith are;

* There is only one God

* All divine religions come from the same God

* All humanity is one race and the members of one family.

The Bahá'í faith embraces people from more than 2 110 ethnic, racial and tribal groups in over 235 countries. There are no clergy in Bahá'í. Bahá'í sacred scriptures are read morning and evening. Community meetings, called Feasts, take place every nineteen days. There are eleven Holy Days in the Bahá'í calendar, nine of which require the suspension of work or study.

The worldwide Bahá'í community is governed by elected councils called Spiritual Assemblies. A Spiritual Assembly is formed when there are nine or more adult Bahá'í members. These Assemblies are responsible for overseeing the affairs of the community under their jurisdiction and, in particular, serving Bahá'í followers in the area. Spiritual Assemblies oversee marriages and funerals and they also provide counselling services and support to patients.

The Bahá'í Faith in South Africa

There are over 6 000 adherents of the Bahá'í faith in South Africa. The earliest known Bahá'í activity was in 1911 at the home of Agnes Cook in Sea Point, Cape Town. In 1920, a Bahá'í teacher from the USA, Miss Fanny Knobloch, she spent time in Cape Town, Johannesburg and Pretoria. The first local Bahá'í Assembly formed in Pretoria in 1925 but lapsed in 1931 due to the movements of the Bahá'í.

In 1940, a South African from Ladybrand, the painter Reginald Turvey, returned to South Africa from England where he had become a Bahá'í through his association with the well-known painter, Mark Tobey. In 1953, a number of Bahá'ís from North America settled in South Africa and established the Bahá'í faith more firmly. However, because of the system of apartheid, practiced and legislated in South Africa, the Bahá'í faith was taught, without exposure, for 32 years on a one-to-one basis.

**Health and Healing**

Bahá'í teachings regard human beings as spiritual beings. They believe that we all possess an immortal soul and that this soul is a Divine Trust. The human body is referred to as the "Throne of the Inner Temple."

Bahá'ís believe that good health is the greatest of all gifts. The healthier the body, the greater the spiritual power, the intellectual power, the power of memory and the power of reflection. Baha'u'llah taught that religion and science can be seen as the two wings of a bird, both of which are essential for flight. And so, healing consists of material and spiritual processes, both being essential and complementary. Bahá'ís believe that spiritual healing on its own is not, and cannot be, a substitute for material healing, but is a valuable adjunct to it.

_Alcohol, Drugs and Tobacco_

The consumption of alcohol, intoxicants, habit-forming and mind altering drugs is prohibited, unless they are prescribed by a qualified physician. Bahá'ís believe that when used for other than medical purposes, these drugs interfere with spiritual well-being and pose a threat to physical health. The smoking of tobacco is strongly discouraged.

_Diet_

There are no dietary restrictions in the Bahá'í faith. Bahá'ís recognise the importance of diet and nutrition in promoting health and preventing illness. They are encouraged to be moderate in whatever they eat. Each year, from March 2nd to March 20th, all Bahá'ís from the age of fifteen abstain from food and drink between sunrise and sunset. Fasting is symbolic and used as a reminder of self-restraint, self-discipline and an abstinence from carnal desires. Followers who are over seventy, who are engaged in hard labour, who are ill, pregnant or menstruating are exempt from fasting.

_Donation of Organs and Blood_

Organ donation is regarded as a noble gesture; however, bodily remains must not be cremated or taken more than an hour's journey from the place of death. This is to show respect of the body which was once the temple of the soul. Bahá'í followers can donate blood and receive blood transfusions.

_Circumcision_

Bahá'ís are not advised on a particular course of action with regard to male circumcision, but female circumcision is considered a mutilation of the body.

_Prolongation of Life_

The Bahá'í teachings also do not counsel about removing life support in medical cases where life support prolongs life. This decision is left to those responsible, and includes the patient when possible.

_Death_

The Bahá'í faith teaches that the soul is eternal and that after death; the physical body should be treated with respect. An autopsy is acceptable in cases of medical necessity or if legally required. Bahá'í followers are allowed to donate their bodies to medical research for restorative purposes. Embalming and cremation are prohibited. The body should be buried within an hour's journey from the place of death.

******

**BUDDHISM**

**Anecdote**

A twenty-year-old Buddhist monk from Cambodia was in same-day surgery for a hernia repair, accompanied by his mother, aunt, and male cousin. When Lisa, his nurse, entered the room, she greeted him, put her hand on his shoulder and directed him to a chair across the room. The patient suddenly jumped from her in horror. His mother and aunt lunged at Lisa, shouting at her in Cambodian. Lisa fled the room and called a "code gray", which summoned all male hospital personnel to the area.

When everyone arrived, the cousin was in the corner comforting the patient. Security questioned the patient, but he did not speak enough English to respond. His cousin explained that the patient was a monk and could not be touched by a woman. Should it happen, he was not to look at her, move, or respond in any way. Even the slightest tensing of the muscles would be interpreted as showing desire and a breaking of his vows. Because of the incident, he would have to do great penance.

Sadly, this incident could have been avoided. Apparently, the need for strict sexual segregation had been thoroughly discussed with the physician prior to admission. The doctor assured them that there would be no problem. However, he neglected to convey this information to the staff. When questioned, the physician said he thought it would be amusing to see how everyone reacted. The hospital made arrangements to assure that thereafter the patient would have contact only with males, but the damage had already been done (Galanti 2003:50).

**Introduction**

Buddhism began in India about 2, 500 years ago, during the life of an Indian prince called Siddhartha Gautama. He saw that there was suffering in the world and wanted to understand why this was and how to end it. Through meditation he found the answers. He then became known as Buddha, which means "enlightened one". For the rest of his life he travelled through India and taught what he had learned and how people could leave suffering behind.

Buddhists follow the Buddha's teachings. They do not worship the Buddha as a god, but see him as a guide for their lives. Today, there are over 400 million Buddhists all over the world. Many live in Asia, Japan, Sri Lanka and Thailand.

**Basic Beliefs**

In his first sermon after his enlightenment, the Buddha explained the human condition in terms of the Four Noble Truths. These are the teachings:

* The first Noble Truth characterizes human existence as one of deep-seated unhappiness and endless suffering.

* The second Noble Truth is that suffering is found in craving - human greed, selfishness and discontent.

* The third Noble Truth establishes that suffering is stopped when craving stops.

* The fourth Noble Truth prescribes that freedom from craving can be attained by means of the Eightfold Path.

The Eightfold Path's "Right" views are:

* Right View - attempting to see reality as it is, without preconceptions and biases.

* Right Intention \- constantly attempting to rid oneself of incorrect and immoral tendencies.

* Right Speech - abstaining from lying or saying unkind things.

* Right Action - thoughtful and kind behaviour towards others.

* Right Work - certain jobs hamper a person's freedom and happiness or could harm others or the environment.

* Right Effort - determine to do well and to achieve set goals.

* Right Mindfulness - careful weighing of one's words and deeds.

* Right Concentration - dwelling on something with inner tranquillity.

In their daily lives, Buddhists try keep the following five promises:

* Not to kill or harm living things.

* Not to steal.

* Not to use their sexuality in a harmful way.

* Not to lie or say unkind things.

* Not to drink alcohol or take drugs.

Buddhists believe that by following the Buddha's teachings they will eventually leave behind all suffering and gain a state of peace and happiness known as Nirvana.

**Buddhism in South Africa**

The first Buddhists to enter South Africa were Thai monks who were shipwrecked in 1686 near Cape Agulhas. However, it was only with the arrival of Indian immigrants in 1860 that Buddhism became a living religion in this country. About 3% of the new inhabitants were Buddhists. Buddhism has an estimated 20 000 adherents in South Africa today, hence to have a Buddhist as patient may not be an everyday experience.

**Health and Healing**

Buddhists believe that to keep the body in good health will keep the mind clear and strong. They also believe that Enlightenment can be attained in this life and for this reason; life in all its forms must be treated with the utmost respect. In fact, the first of the Buddha's five precepts forbids the taking of life, in any form.

Once Enlightenment is attained, the individual wins the final liberation to Nirvana. It is important to note that after reaching Nirvana, the individual continues to live. Such a person is in a state of mind where complete tranquillity, awareness and purity prevail.

_Dietary Requirements_

Many Buddhists adhere to a vegetarian diet which may also exclude fish and eggs and other animal proteins such as milk and cheese. There are a wide range of dietary practices in Buddhism and it is left to the individual Buddhist to decide where he or she stands on the issue of vegetarianism.

_Hygiene_

The attitude of Buddhist patients towards personal hygiene may vary greatly, and it will be necessary to enquire the extent to which it is practiced. While some may follow generally accepted principles when it comes to personal hygiene, others may desire to wash before meditation and may even require washing after defecation and urination. (Neuberger 1987:43)

_Religious Practices_

Buddhism is not a dogmatic religion and therefore no specific practices are prescribed. The extent, to which the Buddhist patient will require special provisions to be made, will differ from person to person but time and space for meditation, prostrations and/or chanting should be provided. Although there are no religious restrictions for medical intervention on holy days, Buddhists could be filled with emotions and healthcare professionals should consult, out of courtesy, whether medical or surgical procedures have been scheduled on such days. (Boyle and Andrews 1989:383)

Many Buddhist practice meditation and they sit motionless for hours at a time and have learnt to ignore the physical pain that arises when sitting in a cross-legged position. In fact, learning to ignore pain is one of the first barriers the novice mediator needs to overcome. Such patients may have unusually high pain thresholds as a result.

_Death and Dying_

If there is hope for recovery and continuation of the pursuit of Enlightenment, the prolongation of life is encouraged and supported. Buddhists consider the body as a shell and hence there is no religious prescription regarding autopsy or the body's disposal. Donating a body part that will help someone else is regarded as an act of mercy and encouraged.

Zen Buddhism has a strong martial tradition, and patients from this tradition may, at a late stage of their sickness, turn down all further care and prefer to die on their own terms. For all kinds of Buddhists, it is important that one should die with the mind in as clear a state as possible, and Buddhist patients may well insist that even palliative care should not consist of morphine or other mind-altering drugs, or at least, that these should be kept to a minimum.

******

**CHRISTIANITY**

**Anecdote**

"An elderly, devout Catholic lady came to the surgery just before Easter, very distressed because she had an acute attack of gout, a condition from which she had never previously suffered. She was distressed not only by the pain, but also because she associated gout with overindulgence and placed great emphasis on living a simple life. Her doctor, who knew about her religious faith, asked her about Lenten austerities.

It emerged that she had been fasting quite strictly and had lost a little weight. The doctor pointed out that starvation and dehydration, as well as excess, can precipitate gout, and advised her to moderate her austerities in future. She was much comforted and to date has had no further episodes."

(Fuller, JHS and Toon, PD 1988: Medical Practice in a Multicultural Society. Oxford: Heinemann Professional Publishing, 101.)

**Introduction**

Christians follow the teachings of Jesus Christ, who lived 2000 years ago in Palestine. Christians believe that Jesus is the son of God and he came to earth to save people from their sins. After Jesus' death, his disciples spread his teachings far and wide. Today there are approximately three thousand million Christians and many different Christian teachings. Christianity is the world's largest religion.

**Basic Beliefs**

One God

Christians believe in one God and He created the world and watches over it; they also believe that God is kind and loving. He is always ready to forgive wrongdoing if one is truly sorry and promises to follow Him. Christians believe that He is everywhere and sees and knows everything. One becomes a Christian when one accepts Jesus Christ as Lord and Saviour and repents one's sin. In this way, one inherits eternal life after death. Christians believe that God acts in three distinct ways: as God the Father, who made and cares for the world; as God the Son, who came to earth as Jesus; and as God the Holy Spirit who is at work in the world. These three ways are known as three persons in one God and constitute the Holy Trinity.

Ministry and Death of Jesus Christ

Jesus began a ministry of teaching and healing at the age of thirty. Large crowds came to hear him teach. He gathered twelve men around him and they became his disciples. During the Pesach (Passover) festival in Jerusalem Jesus was arrested by Roman authorities and charged with blasphemy by the religious leaders of the day. He was sentenced to death and crucified just outside Jerusalem. Christians have accepted the cross as a very important symbol because it reminds them how and why Jesus died.

Resurrection, Ascension and Return

Christians believe that Jesus rose from the dead three days after he died. After his resurrection Jesus appeared several times to his disciples. Forty days after his resurrection he ascended to heaven to be with God once more. Then after his ascension, the Holy Spirit was poured into the hearts of believers during the feast known as Pentecost. The main events in the life of Jesus; namely his birth, resurrection and ascension, together with the coming of the Holy Spirit, are annually commemorated by Christians worldwide. Christians believe that Jesus will come and judge those on earth at the end of time. His return will be unexpected and will bring about a renewal of the whole of creation.

Worship

Christians worship on Sundays and on Christian festivals and many Christians meet in church for services that include hymns, prayers and readings from the Bible. An important part of the Christian service is when worshippers remember the Last Supper that Jesus had with his disciples before his death. This ceremony, instituted by Christ during that last meal, has different names such as the Lord's Supper, Holy Communion, Eucharist and Mass. Bread and wine (or grape juice) are served in order to commemorate that Jesus' body was broken and his blood was shed.

**Christianity in South Africa**

Christianity came in two waves. Firstly it came as the faith of European colonists who settled in the country during the second half of the seventeenth century. The second wave came with the missionaries at the end of the eighteenth century. Today more than 70% of South Africans belong to one of the many Christian denominations. A fascinating aspect of Christianity in South Africa is the emergence of the African Indigenous Churches. These churches are presently the fastest growing body of Christians in the country.

**Health and Healing**

The healing aspect of Jesus' own ministry has drawn the Christian Church into a ministry of caring for the sick. An essential element in the Christian response to sickness, pain and suffering is the life, death and resurrection of Jesus. Early Christians believed that disease and illness were the result of sin. Despite this emphasis on sin, the Church did not totally disregard medical progress. Initially, the priest worked beside the doctor and the sick were encouraged to see physicians as servants of God. Through the centuries, medical and religious dimensions of healing appear have become separated and specialized. However, there are many parallels between the mainstream medical approach to physical health and the traditional Christian care of the spirit.

Due to the existence of many denominations of Christianity, it is generally very difficult to present a single outlook on healthcare, and particularly, on controversial issues surrounding healthcare. Issues such as abortion, artificial insemination, blood transfusion, euthanasia and organ donation are at times meet with very different, and often, directly opposite responses. If you consider that groups like Jehovah's Witnesses and Mormons, although not "formally" Christian, are often included when the Christian viewpoint is sought, it becomes clear just how difficult it is to find common beliefs. Therefore, healthcare professionals should consult with each patient and their family individually regarding permissible and / or prohibited medical practices.

_Pastoral Care_

Most Christians would have no objection being visited or prayed for, by a visiting pastor or priest from a denomination other than the one they belong to but patients would welcome a visit from their own pastor before and after a serious operation. To make such a visit possible would be highly appreciated by both the patient and the family concerned, even if the visit has to take place outside normal visiting hours.

In many hospitals, there is a Bible in the patient's locker; healthcare professionals should enquire whether a patient would prefer his or her own Bible at the bedside. Some patients wear a crucifix around their neck which might need to be removed before an operation (as is done with all jewellery) and staff may need to explain the need to do this.

Some Christian denominations believe that a service be held specifically to pray for healing. This often accompanies "the laying on of hands" where the patient is touched by the person conducting the service. Many testimonies of healing have been recorded by this method. In a hospital context, it may disturb or even offend patients if certain denominations pray loudly for healing of someone in the ward. Staff should be aware of ways to deal sensitively with this.

Orthodox Christians may bring a small family icon to hospital and depending on the value of the icon, staff may suggest that it be left in the care of a family member and that it be brought back whenever the patient is visited.

_Mass or Eucharist_

If a patient expresses the desire to attend mass; this should be arranged with the hospital chaplain if the hospital has a small chapel and the patient is not bedridden or in a serious condition. If the patient is unable to attend such a service, staff should try and create a space and the opportunity for a clergyman to administer the sacrament at the patient's bedside.

_Dietary requirements_

Christians do not have any particular dietary requirements, however, during Lent, when the suffering of Christ is commemorated, many Christians fast. Lent stretches over forty days from Ash Wednesday to Good Friday. Although the sick are never bound to observe this custom, some patients may still want to fast. During this important time of year, healthcare professionals must be sensitive of the need to fast and should discuss the advantages and disadvantages with their patients.

_Death_

If a patient is a member of the Greek or Russian Orthodox Church, the local orthodox priest should be asked to visit the patient. In most cases, the priest will hear the last confession, anoint the patient with oil and give communion. Many Orthodox Christians attach considerable importance to this event. An orthodox patient can be laid out as normal, since there are no restrictions about handling the body.

When a Catholic patient is dying, the priest will normally minister the "sacrament of the sick", which is also called the "last rites". The priest anoints the patient with oil and prays for God to ease the patient's suffering and administers absolution which is a statement of God's forgiveness for the patient's last sins. When a Catholic patient dies, after receiving the sacrament of the sick, the family may ask for the patient's hands to be placed in an attitude of prayer, i.e. holding a crucifix or rosary.

For a patient who belongs to one of the Protestant churches, there are no specific rituals to be followed. At the time of death, the family may request their pastor or the hospital chaplain to be present and pray for the patient. There are also no particular proceedings with regard to the laying out of the body.

Excursus: Jehovah's Witness

The British press has been following an emotional story about religious belief and patient autonomy. In October 2007, Emma Gough gave birth to twins. Complications from the delivery led to bleeding and her doctors said she'd need a blood transfusion to survive. But Gough and her husband are devout Jehovah's Witnesses and she refused the transfusion. She died hours later

The case has led to a range of reactions in the UK - from accusations that doctors made mistakes resulting in the complications to disbelief that a mother would choose to forgo treatment in this way. Others are trying to get a better understanding of Jehovah's Witnesses and their beliefs. Did Gough's doctors do the right thing by not providing the transfusion?

Here's what the head of ethics at the British Medical Association told the BBC about situations involving an adult who refuses treatment on religious grounds: "It's something we just have to live with - the alternative would be to change the law, change the human rights law. It's just too important that we all as individuals are able to make our own decisions." (news.bbc.co.uk/1/hi/england/shropshire)

The case of the 22 year old Emma Gough focused attention on the Jehovah's Witnesses and the extreme positions that their beliefs ask them to occupy. For this reason, this brief excursus is presented here.

Not generally regarded as part of Christianity, the Jehovah's Witnesses is a group or a sect that derived from Charles Russell (1852-1916). This group emphasizes biblical literalism and preaches the immediate coming of the Kingdom of God. Identification of the religion as Christian is debated because they dispute the Trinity, which most Christian religions regard as a fundamental doctrine. They believe God (Jehovah) is the creator, Jesus (His son) is separate and not equal and the Holy Spirit is Jehovah's active force. Christ is regarded as the only means by which to approach Jehovah in prayer, and the means of salvation. They believe that Jesus is the head of the Christian Congregation.

Jehovah's Witnesses believe that Jesus' death was necessary to atone for the sin brought into the world by Adam. Jehovah's Witnesses believe that during the imminent war of Armageddon, the wicked will be destroyed, and survivors, along with millions of others who will be resurrected, will form a new earthly society ruled by a heavenly government and live forever in an earthly paradise.

Jehovah's Witnesses believe that the Bible prohibits eating blood, and this includes the storage and transfusion of blood, even in cases of emergency. This doctrine was introduced in 1945, and has been elaborated upon since then. Accordingly the organization has established Hospital Information Services responsible for education on and facilitation of "bloodless surgery." This service also maintains Hospital Liaison Committees whose function is to provide support to adherents. (Wikipedia)

******

HINDUISM

**Anecdote**

When Leila and her husband had their first son, they wanted to name him in the traditional Hindu manner, which meant waiting until he was seven days old. Before choosing a name, they would have to consult an astrologer who would give them a list of auspicious letters based upon the time and date of birth. These letters are given to her husband's sisters, who would then choose a name beginning with one of the letters on the list.

What they had not counted on was the response of the hospital. Despite the fact that Leila was a nurse, she did not realize the importance placed on filling out the birth forms. When they refused to fill in the baby's name, the nurse reported her to the head nurse. This resulted in visits from the hospital administrative nurse, the chaplain, and the social worker. They all seemed concerned about Leila's plans for the baby once they got home. When she asked the social worker why everyone seemed so disturbed, the social worker admitted that they were worried that she wasn't bonding properly with the baby - why else would she not have named him?

Leila and her husband were both shocked and embarrassed that anyone would think they did not want their child. She quickly explained the Hindu tradition to the social worker who noted the information for the nursing staff. Leila also recommended that, in future, a patient who refuses to fill out the child's name should be asked why before any misunderstandings result.

Leila was told to call the hospital as soon as they named the baby, but apparently, the hospital could not wait and on the morning of the seventh day, Leila received a call from the social worker, wanting to know the child's name so the forms could be completed.

When Leila asked her mother and grandmother why they are to wait until the seventh day to name the child, they told her that it is the day the stump of the umbilical cord falls off, and thus the baby's first day of life. It is also the first time that the baby really opens his eyes and looks around. Although they did not mention it, it is probably related to high infant mortality rates (Galanti 2003:50),

**Introduction**

Hinduism originated about 4000 years ago in India and about 80 percent of India's population regard themselves as Hindu. There are also about 30 million Hindus elsewhere in the world. Hinduism is known for its tolerance. It has no fixed dogmas, it has no international council recommending any particular common conduct and it has no centralised community life. Yet, Hindu tradition is so strong and strangely timeless that homogeneity prevails.

**Basic Beliefs**

The Divine and the Self

Hindus believe in a great soul or spirit, called Brahman. This great soul or spirit is omnipresent and omniscient. They also believe that every person has his or her own soul, which is called atman. It is believed that when a person dies, the soul lives on and is reborn in a new physical body and this rebirth is called reincarnation. Reincarnation happens repeatedly and can keep the soul trapped in a cycle of birth, death and rebirth. This cycle is called samsara and Hindu's try to escape from samsara and reach moksha or liberation, when the soul (atman) joins with Brahman. The Law of Karma or Action governs the cycle of samsara. The action of previous lives determines the quality of the next embodiment. During a lifetime, the law of karma also influences one's circumstances and so every good action takes a person closer to moksha, whilst wrong action takes a person further away.

The Gods

Hinduism symbolically portrays the greatness and vastness of Brahman's power through thousands of Hindu gods and goddesses. Each one represents a different aspect of Brahman's power. The three most important gods are:

* Brahma (The Creator)

* Vishnu (The Protector)

* Shiva (The Destroyer)

There are two major schools of belief in Hinduism: Saivism - a belief in Shiva and all his aspects - and Vaisnavism - a belief in Vishnu and all his aspects. At times of great crisis Vishnu the Protector assumes the form of a person or animal known as an avatar and two such avatars are Krishna and Rama.

Worship

Patterns of worship vary amongst Hindus, some may worship all the gods and goddesses; some do not worship any at all; and others may choose a particular god or goddess who is special to their family. The Hindu calendar determines the day, time or type of worship. Hindu worship is called puja and is performed both at home and with the community. Most Hindus have a small shrine at home, and communal worship is held at a mandir (temple). A mandir is a lively, colourful place where festivals are observed and they are considered the religious hub of the community. Hindus remove their shoes as a sign of respect and ring the temple bell before entering. Priests are given flowers, fruit and sweets to offer to the god or goddess. After the prayer, the priest gives some of these offerings back to the worshippers as a sign of the god's or goddess's blessing.

Festival of Deepavali (Diwali)

The most widely celebrated Hindu festival is Deepavali (deepa \- lamps; vali \- a row), the festival of light (sometimes abbrieviate to Divali). Deepavali is linked to the triumph of good over evil as told in the Ramayana. This scripture recounts the story of prince Rama who was banished to the forest for fourteen years and when he defeated the demon king Ravana he returned triumphantly and became king. He was guided back from exile with rows of lights that were lit along his path, around homes, and temples. Deepavali also marks the beginning of the new business year and Hindus offer prayers to Lakshmi, the goddess of wealth. All pathways and entrances to homes and businesses are lit with lamps so that Lakshmi may enter. It is a time of goodwill and celebrated with fireworks, feasting, singing and dancing.

**Hinduism in South Africa**

Hinduism arrived in South Africa in 1860 when indentured labourers came from India to work on the sugar plantations in Natal. Very soon after their arrival, Hindus built shrines and temples and the oldest Hindu temple was erected in 1864 near Umzinto on the south coast of Kwa Zulu-Natal. It is estimated that there are approximately 800 000 Hindus in South Africa.

**Health and Healing**

Hindus believe in the law of opposites like; good and evil; pain and pleasure; suffering and healing. Anyone who believes that one part of this duality is the whole truth is led into one-sided and unbalanced action. Suffering and sickness become problems when they appear to be final and inescapable truths. When Hindus realise that the self is not bound forever to the world of ill-health and pain, then suffering no longer occurs. Being or becoming aware of Brahman isolates the individual from suffering because it involves detachment as opposed to attachment and suffering arises only when individuals attach themselves to matters of objects, which have passing value as if they were permanent.

_Death_

Hindus believe that only the body dies in death and that the soul moves on and returns to earth in either a better or a worse form. This reincarnated form would depend solely on that person's action, that person's karma. Rather than being the termination of life itself, death is seen as an interval between lives and is accepted as a natural progression towards liberation.

Issues like abortion, artificial insemination and organ donation are not met with any objections. There are also no religious customs or restrictions when it comes to prolonging life, or exercising a right to die. Most Hindus prefer to be cremated after death and then have their ashes immersed in flowing water. This rite is most often performed within 48 hours of death. A mourning period of forty days is usually observed.

_Ritual Purification_

Hindus believe that purification of the body is just as necessary as purification of the mind. Daily cleansing is done with the pouring of water over the body. A shower is preferred to a bath and is favoured first thing in the morning. This is particularly true for elderly Hindus, who like to bathe early in the day before saying their prayers. Hindu belief suggests that bathing does not only render one physically clean but also spiritually, so a patient might be particularly keen to carry out this religious duty.

_Food Restrictions_

Many Hindus observe strict vegetarian diets which include not eating any meat, fish or eggs. In South Africa, there are Hindus who eat lamb and chicken but abstain from eating beef and pork. It is not possible to know off-hand whether the patient is strictly vegetarian and healthcare professionals should simply ask the patient or the family.

_Fasting_

Fasting is used extensively in the Hindu faith. This might mean a complete abstention from food, meat or salt during special festivals or on certain days of the week. The issue of fasting is a sensitive one and decisions regarding fasting must be made in consultation with the patient and their family, but ultimately, the decision to fast rests with the patient.

_Modesty_

Hindu women are reluctant to undress for an examination and would prefer a female physician or nurse to do the examination. Hindu women would be horrified to be given a bath by a male nurse and equally, many Hindu men would be appalled to be given a bath by a female nurse. Total privacy for bed-baths is essential. These issues must be respected because a disregard of their modesty will cause extreme distress. Once again, sensitivity, understanding and simply asking appropriate questions can help eradicate unnecessary discomfort and stress.

_Worship_

Hindus require time for meditation and prayer. A space where someone could pray and meditate alone is often requested, but others find it quite acceptable to pray in bed. In either case, small idols or pictures of gods would be kept at the bedside.

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**ISLAM**

**Anecdote**

"What did I do wrong"? A senior student at the Ann Latsky College of Nursing in Johannesburg asked at the annual retreat of the college for its students.

She was referring to an incident when she barged into a ward bathroom the previous evening and found a Muslim lady on the floor. Her first impulse, she explained, was to help the patient up because she thought the patient had collapsed, but then attentively realized that the patient was praying and hadn't fallen. She then left the bathroom as quietly as possible.

The student was assured by the facilitator that she did nothing wrong and that she acted wisely when she didn't interfere or interrupt the patient's prayer.

It was recommended that in order to avoid incidents like this in future, nursing staff should consult patients regarding prayer times to assure privacy.

**Introduction**

Followers of Islam are called Muslims. Islam means "submission" which signifies that a Muslim is someone who submits to the will of Allah (God). Muslims believe that true success in this world, and in the world to come, can only be achieved through obeying Allah's commands. Islam also means "peace", believing that true peace can also be achieved through obedience to God as taught by the Prophet Muhammad ("peace be upon him").

**Basic Beliefs**

Muslims adhere to the following Articles of Faith:

Belief in Allah

The most important belief of Islam is that Allah is the one true God who created the world and everything in it. Allah is the one and only God who deserves to be worshipped.

Belief in the Prophets

Muslims believe in the prophets of whom Muhammad is regarded as the most important. He is the last and final prophet chosen by God to bring His message to humankind.

Belief in the Books

Muslims believe in all the prophets of Allah as sinless persons who had great and noble qualities, who were obedient to Allah and who were sent by Him. Several prophets received divine revelations which were written into 104 books of which only four have been preserved, namely;

* The Tawrat (Pentateuch) - given to Moses,

* The Zabur (Psalms) - given to David,

* The Injil (Gospel) - given to Jesus and

* The Qur'an \- given to Muhammad and regarded as the correct and final revelation, replacing all the other revelations from God to humanity.

Belief in Angels

Angels are often mentioned in the Qur'an. There is the archangel Jibril (Gabriel), the angel of revelation, Mikal (Michael) the angel of providence, Israfil, who will blow his trumpet on Judgement Day and Izrail, the angel of death.

Belief in the Last Day

Muslims believe the dead will be resurrected and judged according to their actions on the Day of Judgement, also known as The Last Day. However, good actions alone are not sufficient for redemption because the intention behind the action is crucial. After weighing the good and evil actions, reward and punishment will be meted out.

Right Conduct

The Qur'an supplies Muslims with comprehensive guidance for everyday life and a wide range of acts for Muslims are derived from its teachings. These involve Muslims from both sexes and stretches from birth to death. There are laws that prohibit certain foods, such as pork, and other consumable substances such as alcohol, as unsuitable for human consumption, and laws that declare other foods and substances as permissible. These laws constitute a wide-ranging framework for daily living for Muslims. Included in this framework are also regulations that cover relationships between the sexes.

Religious Duty

Most prominent in the religious duties incumbent upon all Muslims are the Five Pillars. They are so called because they form the very foundation on which the faith rests.

* Declaration of faith - The first of the five pillars is the basis on which the others stand. Every Muslim should declare that: There is no other god but Allah and Muhammad is his messenger.

* Ritual prayer - Muslims are expected to pray five times a day - at dawn, just after 12pm, in the late afternoon, just after sunset and after dark. Before prayer, Muslims will ritually purify themselves - this purification consists of washing hands and arms to the elbows, the feet to the ankles, the nostrils and ears and rinsing the mouth. Muslims will usually unroll a prayer mat, remove their shoes and face the Ka'ba in Mecca (Saudi Arabia) for prayers.

* The Fast of Ramadan - It was in the month of Ramadan (pronounced Ramzhaan), the ninth month of the lunar calendar, that the Qur'an was sent down from heaven and given to Muhammad. To commemorate this, Muslims observe a month-long fast. During this month, most adult Muslims abstain from food, drink, smoking and sex. On the spiritual side, it requires that Muslims refrain from thinking bad thoughts and saying or doing bad things.

* Almsgiving - It is the duty of every Muslim to give to the poor and the needy. At least 2, 5% of a Muslim's possessions must be given away at the end of the year. The personage is at liberty to decide whether to give it directly to needy individuals or to give to a charitable organization.

* Pilgrimage - Once in every Muslim's life, he or she is required to make a pilgrimage to Mecca, if he or she has the means to do so, is free from debt, healthy in body and mind, wealthy enough to cover all expenses for completion of the pilgrimage and for the maintenance of all dependants, and able to travel in peaceful conditions. Only Muslims are allowed to enter Mecca and the pilgrimage serves as a physical demonstration of Muslim equality and unity.

**Islam in South Africa**

Islam entered South Africa in two ways and in two clearly discernible periods. Firstly, Muslims entered either with, or shortly after, the first colonial settlers during the second half of the seventeenth century. These settlers came from the Indonesian islands. The second wave included contract labourers, of which seven per cent were Muslims and they came from India in 1860. It is estimated that there approximately 600 000 Muslims, of all races, in South Africa.

**Health and Healing**

Central to Islam is a theme of oneness. God is one and indivisible and therefore life, of which He is the author, is indivisible as well. Since wholeness is the guiding principle of well-being and closely related to the concepts of health and illness, methods of caring and curing must follow this holistic perspective. Illness is not merely somatic (body) but is seen in a psychosomatic (mind & body) context. Furthermore, there is repeated emphasis that suffering, especially sickness, cancels sins.

Muslims believe in life after death and death is only one stage in God's overall plan for humanity. So, the death of a loved one is seen as a temporary separation and the actual death is God's will. Devout and pious Muslims believe that suffering and death are part of God's plan and it's their duty to accept, however difficult, whatever God sends. Excessive weeping at death is therefore frowned upon since that would contradict an acceptance of God's will.

_Prayer and Ritual Purification_

The Qur'an instructs Muslims to wash before they pray and since there are five daily prayer times, this purification ritual takes place five times a day. In midsummer the first prayer can be fairly early, whilst in winter the prayer times run closer together. These purification rituals will certainly put great demands on staff but understanding and assistance will minimize any psychological stress that the patient may experience. An ill Muslim, even terminally ill, would most likely want to continue the daily prayers and purification rituals for as long as possible. It would greatly help if staff could ascertain the exact times involved and render assistance to ensure privacy. A small side room into which a bed or chair could be wheeled or failing that, curtains round the bed would help.

_Dietary Requirements_

Most Muslims observe the dietary rules of Islam and while in hospital many will follow a vegetarian diet, unless halaal meat can be provided. (Halaal - suitable for human consumption and killed according Islamic Law.) Muslims do not eat pork or pork products, such as ham, bacon, or food which contain ingredients like pork fat.

All other meat is allowed but only if it is halaal. Muslims can also eat kosher meat, if halaal meat is not available. Fish is permitted, but fish that have fins or scales, except prawns, are forbidden. Dairy products are acceptable provided that only halaal animal rennet is used. Some types of insulin are made from pork products and therefore these will be prohibited for use. Alcohol is expressly forbidden even when used for medicinal purposes.

Methods of cooking and serving are also extremely important, for example: utensils used for ham, and then for the salad, without washing them in between, will render the salad not fit for consumption.

_Fasting_

Fasting in the month of Ramadan is of considerable importance to all Muslims because it's a time of spiritual renewal and is normally preceded by the settling of disputes, ill-feelings or problems. Even though illness is a valid reason for obtaining an exemption from fasting, this is a time when personal matters are put in order and its understandable that somebody who is seriously ill may regard it as a last opportunity to set things right. The general rule is that the elderly and those in poor health do not fast for the whole month but do fast as much as they can manage. This is an option that patients may choose.

Even if Muslim patients decide to fast for only a few days, special arrangements need to be made. For instance, they will need a meal before dawn and another after sunset, as well as a glass of water and a bowl to rinse their mouth before prayer. Fasting also includes not inserting anything into the body by mouth, nose, injection or suppository, from dawn to sunset. This can make pain control difficult and can be a source of considerable frustration to healthcare professionals. However, understanding that fasting brings comfort to the patient should ease the caregiver's frustrations. So, allow the patient the opportunity to make a decision about whether or not to fast without undue pressure. The imam would be a good person to advise the patient when it comes to difficult decisions on the advisability of fasting.

_Muslim Festivals_

Important Muslim festivals include: Eid (pronounced Eed.) ul-Fitr which marks the end of Ramadan and Eid ul-Adha (pronounced Azha). Eid ul-Adha commemorates Abraham's willingness to sacrifice his son (Ishmael and not Isaac, according to Islamic tradition). During these important festivals patients would wish and certainly prefer to go home. However, if this is not possible, routine tests and examinations should be avoided.

_Modesty_

The strong need for modesty may cause problems in a hospital setting. Where possible, Muslim women should always be examined and treated by women doctors and nurses and men by men. Sensitivity in this area can avoid many unnecessary problems.

_Death_

When a Muslim is dying, it is not necessary for a religious leader, such as an imam or maulana, to be present. Family members often stay at the bed and pray. The Islamic statement of faith, namely "There is no god but Allah and Muhammad is his prophet", will be said first of all since these are the last words that a Muslim should say. If at all possible a dying person should be helped to sit or lie with his or her face towards Mecca, while a family member whispers the call to prayer in the ear of the dying person. Once a Muslim patient is dead, the body should ideally not be touched by non-Muslims.

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**JUDAISM**

**Anecdote**

A case involving the death of a Jewish patient was resolved due to the cultural competence of the nurse. Matthew Goldstein, an Orthodox Jew, requested to remain with the body of his deceased father until the mortuary came to pick up the body. According to Reyna, the nurse, hospital policy does not allow that, since it sometimes takes hours for the mortuary service to arrive and hospital beds are in great demand. However, since Reyna was taking a class in cultural competence at the time, she was especially sensitive to meeting Mr. Goldstein's needs.

She arranged for his father's body to be moved into a little used and secluded area so he could stay until the mortuary arrived the next morning. Reyna reported that she felt very good about being able to accommodate him. "It required very little work on my part and the family was allowed to grieve in the manner they wished".

It is a Jewish custom that the body of deceased is not to be left unattended. To do so is a sign of disrespect. The custom evolved from early times, in which people went to great lengths to guard the deceased from ghosts and spirits (Galanti 2003, 56).

**Introduction**

Judaism is the religion of the Jewish people. While not distinguishable by race, there is a strong sense of community amongst Jewish people and a sense of loyalty and support for each other. Jews believe that Abraham, who lived in the Middle East more than 4000 years ago, was the first Jew. G-d entered into a covenant with Abraham when G-d chose Abraham and his descendants to be His people, not as recipients of special favour, but so that the world could see the great deeds of G-d. Abraham, in turn, bound himself and his descendants to a personal commitment to G-d. (Jews generally do not write the word God. Writing G-d instead of God is one way to prevent desecrating the name of God.)

Abraham and his family settled in Canaan but after a severe and prolonged famine, his descendants (the "children of Israel") were forced to seek refuge in Egypt. Once there they were enslaved by the Egyptian pharaoh, Ramses II. After many hardships that lasted approximately 400 years, liberation dawned for the Israelites when G-d called Moses to free His people from the yoke of slavery. Moses led the Jews through the Red Sea to freedom. The journey out of Egypt is called Exodus and according to tradition, forty years of wandering in the Sinai desert followed. The leadership of Moses reached its pinnacle at Mount Sinai when G-d renewed His covenant and Moses was given two stone tablets inscribed with the Ten Commandments.

**Basic Beliefs**

Strictly speaking, Judaism has no formal doctrine or creed to which one has to adhere, and "right doing" has always been more important than "right belief." The following main tenets can nevertheless be distinguished:

Monotheism

Belief in one G-d and the explicit commitment of faith to one deity is a consistent feature of Judaism. However, the interpretation of this and the theology associated with it, differed markedly from one period and place to another.

Holy Scriptures

Jews believe that G-d's message to his people is contained in the Holy Scriptures and by studying them, they study G-d. The Holy Scriptures also contain their duty towards G-d and their duty towards others. The Hebrew Bible is called the Tenak. It has three major sections, namely the Torah, (Pentateuch or five books of Moses), the Neviim (prophetic books) and the Ketuvim (the writings). These three components together spell the acronym TNK, or Tenak (pronounced tenach).

Commandments

G-d's commandments come to the people through the Torah, the first books of the Hebrew Bible. Careful study by rabbis revealed that there are 613 commandments covering all areas of daily life. Jewish people are expected to respond to G-d with their whole lives, all the days of their lives.

Different Schools of Thought

Today there are at least three schools of theological thought and social practice in Judaism. Firstly, there is the Orthodox school. Orthodox Judaism regards itself as the only valid and true Judaism and aims to preserve traditional Judaism. Although Orthodox Jews are expected to observe all 613 commandments, certain core practices are generally considered essential to being Orthodox. Among others, these include refraining from activities that violate the Jewish Sabbath and Jewish holidays, observing Jewish dietary laws, obeying the laws of family purity, restricting sexual relations around menstruation and childbirth, and circumcising males.

The second school is known as Reform Judaism which had its origin in Germany during the nineteenth century. It attempts to solve the conflict between inherited tradition and modern life. Reform Judaism took root in North America more than 130 years ago and is now the largest Jewish movement in North America.

The third school of thought is known as Conservative Judaism. This differs from the reform movement but only to a certain degree. Conservative Judaism attempts to combine a positive attitude toward modern culture, acceptance of critical secular scholarship regarding Judaism's sacred texts and commitment to Jewish observance.

There is also an extreme Orthodox sect, called Hasidism. As previously mentioned, Judaism has no formal doctrine or creed to which one has to adhere to, but there are rituals, dietary practices and observances of holy days that are of fundamental importance.

Worship

Jews can choose to worship on their own but they usually pray with other Jews in a Synagogue, also known as a Shul or Temple. There are three prayer times a day; evening, morning and afternoon. Jewish men wear special clothes when they pray. The following are items worn: a kippah or skull cap that covers the head and shows respect for G-d, a tallit or prayer shawl and tefillin ot, (two small leather boxes) that reminds the Jew to obey G-d. One leather box is placed in the middle of the forehead and kept in place with a strap and the other is tied to the arm, and points to the heart. Inside the tefillin ot are tiny scrolls on which passages from the Torah are written.

The most important Jewish prayer is called the Shema. It begins: "Hear O Israel, the Lord is our G-d, the Lord is one. Love the Lord your G-d with all your heart, and with all your soul, and with all your might." (Deut. 6:9) The Shema is written on a tiny scroll and put inside the mezuzah (a small container) which Jewish people affix to doorposts, or any "doorway" in their homes.

Holy Days

The Sabbath is one of the most important holy days. It celebrates both creation and redemption. The Sabbath starts on Friday at sun-set and lasts until sunset on Saturday evening, these times symbolise how the dark is always followed by the light. Shabbat starts with a female member of the family lighting candles and reciting a blessing. Many Jewish people go to synagogue to hear a reading from the Torah on the Sabbath. Judaism accords Shabbat the status of a joyous holy day. In many ways, Jewish law gives Shabbat the status of being the most important holy day in the Jewish calendar. Evidence pointing to this status is that it is the first holy day mentioned in the Bible, and G-d was the first to observe it at the end of Creation.

Yom Kippur is the last of the "Ten Days of Repentance" which begins at Rosh Hashanah, the Jewish New Year. On Yom Kippur (Day of Atonement), many Jews go to the synagogue to pray for forgiveness for their wrongs over the past year. It is also a day of fasting.

The main seasonal festivals include: Passover (Pesach), the Feast of Weeks (Shavuot) and the Feast of Tabernacles (Sukkot). Minor holy days include the Feasts of Lots (Purim) and the Feast of Dedication (Hanukkah).

Rituals

There are many important rituals in Judaism such as the life cycle rituals connected with birth, adulthood, marriage and death, as well as unique dietary practices.

Children are very important in Jewish tradition and symbolise survival and continuity. In order to obey the covenant made by Abraham, the male child is circumcised on the eighth day after birth.

At age thirteen, a Jewish boy is given a Bar Mitzvah ("son of the commandment"). At this age, he starts his adult life and must now obey all the Jewish laws. At his Bar Mitzvah ceremony in the synagogue, the boy recites a prayer and reads from the Torah. For Reform Jews, a Bat Mitzvah ("daughter of the commandment") is the equivalent ceremony for girls but a girl becomes Bat Mitzvah at the age of 12.

The marriage ceremony is called kiddushin, meaning "holy" or "consecrated". This signifies that the relationship between the man and the woman is holy and that marriage is seen as an act of worship. The ceremony often takes place under a canopy (chuppah) which symbolises the couple's house.

When someone dies, the deceased is buried as soon as possible, often on the day of death. Kaddish, (the mourner's prayer) is recited at the funeral and every day for eleven months of mourning.

**Judaism in South Africa**

The first Jewish congregation assembled and established the first synagogue in Cape Town in 1841. Between 1880 and 1914 immigration brought many Jews, especially from Lithuania, to South Africa. Numbering more than 130 000 at one stage, this number has greatly depleted and it is believed that there are less than 100 000 Jews left in the country.

**Health and Healthcare**

There are many prayers for the sick in Jewish liturgy and such prayers are encouraged.

_Circumcision_

Circumcision is performed on Jewish male children on the eighth day after birth. This is normally carried out by a ritual circumciser but can also be performed by the child's father or by a paediatrician. Circumcision may be delayed if medical opinion advises accordingly (Boyle and Andrews 1989:406).

_Sanctity of Life_

The sanctity of life in Jewish law suggests that every human life is absolute and infinite in value. Like many other faiths, Judaism recognises the inner conflict between the essentially divine character of disease and our human efforts to control it. Jewish thinkers regard the conquest of pain and disease as important as the application of water to the thirsty throat in man's striving for survival and prosperity.

_The Here and Now_

Judaism could be described as a "this life" affirming religion. They believe the here and now is what human beings should really concern themselves with.

_Food Restrictions_

Orthodox Jews adhere to kashrut (dietary laws, more commonly called ) very strictly and will only eat meat if it is kosher (fit). The meat of mammals with split hooves, chewers of cud, are suitable for eating as is any fish with scales and fins as well as birds that are not birds of prey.

Orthodox Jews would never mix meat and milk dishes, i.e. they would never eat a steak with cheese sauce. In most cities this doesn't cause catering problems because kosher meal services are readily available. What is often more difficult to deal with is the dietary needs of a less orthodox patient. He or she may keep some, but not all dietary laws. For instance, a person may not eat "forbidden" foods, such as pork and shellfish but will eat "allowed" meat that is slaughtered in the normal way (not the kosher way). They might also not want to mix milk and meat dishes at the same meal. Because there are many variations of dietary laws healthcare professionals should ask the patient or the family regarding dietary needs.

_Visitors_

To visit the sick is an obligation that carries a blessing with it (Mitzvah). A rabbi will often visit and pray with patients in hospital.

_Death_

Although there are no last rites in Judaism, a dying person may ask to see a rabbi. All efforts should be made to meet this request. The nursing staff should find out from either the patient or the family whether an orthodox or reform/liberal rabbi shouls be called. The rabbi will most likely say some prayers with the patient and will try to let the patient say the so-called Shema: "Hear O Israel, the Lord is our our God, the Lord is one." The family is often much comforted by the presence of a rabbi, because there is much to be done at the time of death and they want to assure that they get it right.

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**Conclusion**

The purpose of this book is to encourage healthcare professionals to become more sensitive to the religious needs and practices of their patients. However, it is necessary to extend this call for sensitivity beyond the mentioned religions that are prominent in South Africa.

While many people in South Africa are religious, not all practice or even hold any religious belief or affiliation. Even though this booklet specifically deals with religious beliefs and practices, it should be borne in mind that there are patients who do not adhere to any particular religious tradition. These people equally deserve respect and understanding. Please also note that it would be wrong to assume that those who profess to a religion on a hospital form are actually practicing a particular faith. Therefore, it is best never to assume anything when it comes to religion. If approached sensitively, the patient will often volunteer the required information and it is most often seen as gesture of courtesy if, upon admission, the patient is asked about any particular religious practices that need be borne in mind.

People who do not regard themselves as religious, will often remark; "I am a non-practicing Jew" or "I am a non-practising Muslim" etc. Others might say "I am a lapsed Catholic." Still others might emphatically state that they are agnostics, atheists, humanists, freethinkers, naturalists or secularists. (See definitions.)

Care should be taken not to assume that, when a patient declares that they are "non-religious" that such a person will have nothing to do with religious practices. For instance; a patient, who declared herself agnostic, could still receive Christmas cards and would be happy to have her loved ones with her on Christmas morning and bring her colourfully wrapped gifts. There would most likely be no connotation to the birth of Christ, but Christmas would be seen as part of a cultural tradition.

Also, someone who told the nursing staff that he is a non-practicing Muslim would happily share in the festivities of Eid ul-Fitr at the end of the fasting month of Ramadan. Again, it may be the cultural side of a religious practice or festival that would be enjoyed. Healthcare professionals should, in these cases, be careful not to make assumptions or judge a person's spirituality or their credibility.

I am convinced that healthcare professionals' jobs would be made much easier if they attempt to know something about a patient's religious background and needs. It would also be of great assistance and bring comfort to the patient and their family. To acknowledge a patient's dietary requirements or their customs around prayer and religious festivals, or their cultural needs will give the patient a sense of worth and relief.

If healthcare professionals treat patients as individuals in hospitals, where hundreds are being cared for, their efforts would not go unnoticed or unappreciated.

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**Epilogue**

KEYNOTE ADDRESS DELIVERED BY PROF DETLEF R PROZESKY

AT THE PROMOTION OF SIMPLY ASK, ON 27 NOVEMBER 2008

Thank you for inviting me to address you today on this occasion of the launch of Gerrie Lubbe's book, "Just ask". Gerrie and I have known each other since I was a student and he a young minister and we were both involved in student Christian work. We then went our different ways until we met up again recently and re-established contact.

I'd like to share a few ideas with you this morning on a subject which is close to my heart, very much related to Gerrie's book and what it sets out to do. Let me begin by considering the health care professions to which many of us belong. As we know each profession has unique elements. It has its own scope of practice and service, its own body of knowledge and skills, its own way of regulating itself. One way of classifying the professions is according to the primary focus of their practice - whether it is the material world (such as engineers, architects and laboratory scientists) or whether it is people, human beings (such as teachers, lawyers, social workers, ministers of religion and, of course, health care professions). The people centred professions serve their fellow humans in different ways. They provide help with tasks which oil the wheels of society (such as educating the new generation, drawing up legal contracts, or even keeping people healthy). But what particularly distinguishes the health care professions (together with social workers and psychologists) is that for much of the time they deal with people who are suffering in some way, who are in some kind of personal need.

There is a 15th century aphorism which says that the role of the healer is "to cure sometimes, to relieve often, to comfort always". It has often been quoted since because it is so apt - it so neatly captures the tensions between cure (and life) on the one hand, and comfort (and death) on the other, and relief (and suffering) somewhere in the middle. These tensions have been embedded in the health care professions since their distant beginnings: the great Hippocrates wrote that "it is the suffering individual that physicians must face, not just his pain" - a holistic view of the work of healing, placing the whole individual in the centre. But as the healing professions advanced in science and skill over the last century this began to change: curing came to seem the rule rather than the exception, and it was as if humans were finally conquering disease and cheating death. Looking back I was trained in this paradigm - the paradigm of the powerful doctor, the master of biomedical science who could heal the body and who was not overly concerned by other aspects of human suffering, or at least didn't associate those with the practice of her or his profession. We were certainly taught no skills to deal with anything outside the biological sphere, other than those which came naturally to us (or did not). Yet at the same time we encountered those special teachers who exemplified a more holistic approach in their practice, and felt intuitively that theirs was a better way.

As so often happens in human history it was inevitable that the pendulum should swing back from this kind of biomedical reductionism in practice and training. I would like us to take a brief look at two of the leading figures in this return to holism, George Engel and Cecily Saunders.

George Engel practised and taught medicine in Rochester, New York, in the latter half of the 20th century. His reaction to the reductionism of his time was a return to the understanding of medicine as an art as well as a science, and it was he who in the 1970s developed the "biopsychosocial" paradigm of health care practice - the word is self-explanatory. Engel's seminal work was taken up with enthusiasm by the burgeoning discipline of Family Medicine which continued to develop and popularize it - so much so that medical students in South Africa now imbibe this approach as it were with the mother's milk of their undergraduate training (although it must be said that some of their older teachers still regard it with a measure of skepticism as "that soft stuff"). Students now learn that many patients "somatise", that they present with physical complaints when their real issue is one of unhappiness; they learn to identify and deal with such "help-seeking behaviour" in a consultation. They learn the importance of the role of the family in maintaining health and dealing with illness; they learn how a person's community and physical environment affect health and how such influence needs to be considered in a management plan. They are constantly confronted with the need to examine the ethical implications of medical practice and to analyse situations where these are operating. These new young doctors are now comfortable with the fact that the suffering they will encounter has at least three dimensions - the physical, the psychological and the social. They are more or less comfortable with these dimensions, have some skills to deal with them and expect to include them in their practice. One of our fifth year students recently told me of an experience that he had had earlier that day in one of the wards. He said that a consultant had just informed a woman that she had inoperable cancer, "and Prof., he did it so badly! She started crying and he just walked away. If only he'd asked me to do it I could have done it so much better!"

But there is a further element to the suffering that our patients encounter - and by the way I hate the work "client" in this context: it has a Thatcherite ring to it, and the fact of the matter is that the people who entrust themselves to health professionals do so because they are patients (from the Latin "patiens" - the one who is suffering) and not because they are entering into a business transaction with us. The person who most clearly shows me this fourth element is the admirable Cecily Saunders, who as we all know founded the modern hospice movement. Her epiphany took place against the background of the increasing technical success of the health care professions, of situations where in the words of T.F. Main, "The sufferer who frustrates a keen therapist by failing to improve is in danger of meeting primitive human behaviour disguised as treatment." At the same time this success had led to a distancing of the average person (and the healer) from the unpalatable reality of death and dying, and this at a time when a widespread loss of religious faith in some communities had diminished the avenues of solace available to people confronted with suffering and death. The story is well-known, of how the young medical social worker met a refugee from the Warsaw ghetto who was dying in hospital in London. As she and David Tasma became friends and were able to talk about his coming death it became clear to her that people like David really needed: holistic care, based on the understanding that they were suffering from "total pain"(a word she coined). In her understanding there are four elements to this "total pain": the physical, the psychological, the social and the spiritual; and she spent the rest of her life responding to this understanding by working out how to respond practically to "total pain". As we know the small start at St Christopher's Hospice gave a name to this art (which had never completely disappeared) and palliative care has mushroomed into an international movement which has attracted thousand to its cause and has been a blessing to millions. And as a result the paradigm of training of young health workers today has been even further enriched, by the inclusion of the science and art of palliative care.

Again this inclusion of the spiritual in the process of healing is a return to the past - Hippocrates's well-known oath for new practitioners starts by calling on the gods to witness and judge their intentions and practice: "I swear by Apollo the Physician, by Aesculapius, by Hygeia, by Panacea, by all the gods and goddesses, making them my witnesses that I will carry out, according to my ability and judgment, this oath and this bond."

It is not hard to understand why Dame Cecily included the spiritual dimension in her understanding of suffering. It is surely when people suffer greatly, and witness the suffering of people they love, and when death is clearly approaching, that the great questions around the mystery of existence inexorably present themselves: "Why was I born?" "Why has this suffering come to me?" "Have I done the best I could with my life?" "What about the people I've harmed, wittingly or unwittingly?" "How will the people I love remember me?" "How will the people I love cope when I am gone?" "When will I die, and how?" "Will I die courageously?" "What kind of suffering will I have to go through in the process of dying?" Then there is the mystery of what follows death, the Great Unknown: "What is going to happen afterwards - is it good or bad?" "Will there be an existence to follow?" "Will there be some kind of judgement on my life?" Humans through the ages have placed their hopes on answers to these questions developed by spiritual leaders and thinkers: from the ancient Egyptian Book of the Dead where the heart of the dead person is weighed against the feather of Ma'at, the Truth, and either enters the eternal bliss of the "Field of Reeds" or suffers eternal oblivion; to the Epicurean's expectation of eternal extinction; to the certainties of reincarnation of the Hindu and Buddhist faiths; to the Christian and Muslim promise of eternal life as a reward for faith or good deeds, in the Celestial City or in Paradise.

Although we see examples of militant atheism in celebrities such as Richard Dawkins the fact is that the large majority of the patients that South African health workers will have the privilege of serving identify themselves with a religion and practise it with greater or lesser devotion and orthodoxy. As a result many doctors regularly find themselves in the presence of the fourth element of "total pain", even if they are not aware of it. Even more than that, I remember a priest once remarking that many people no longer talk about these issues with religious leaders and bring such problems to their health practitioners, even if subconsciously. These professionals may have the skills and the confidence to deal with their patients biopsychosocially but may in many cases not even consider that they have a role to play in dealing with what Dame Cecily called the spiritual side of suffering; I think it has been the tradition among us that this is the almost exclusive domain of religious leaders and ministers. But surely what we want of our doctors is for them to be aware of the spirituality of their patients and to be comfortable with it - not only in suffering and death but also in the way patients understand disease and the nature of an appropriate doctor-patient relationship.

This is where Gerrie's book seems to me to fill an important gap, as a resource we as the teachers of young health professionals can use to open up the area of patient spirituality in an appropriate way. Firstly it demystifies the spiritual in our patients by providing solid information about it in all its South African variety and richness, and we can use to approach the subject and discuss it with our students. Secondly it suggests a practical way of bringing the issue into the open in a way which fully respects patient autonomy, by "seeking the patient's view" - "simply asking" courteously if the patient would like any particular religious practices to be borne in mind, any assistance from any source. At the same time, as Gerrie puts it, "the golden rule is not to assume anything when it comes to religion", so the health professional becomes not a guru but a sounding board and if necessary a bridge, responding sensitively to any information provided.

Gerrie's book has been written in response to an awareness of a neglected dimension of health care. I believe that if health professionals and their teachers use this resource their practice will be greatly enriched: they will no longer have to feel nervous or embarrassed or ignorant, and in stead will be able to approach the spiritual dimension in their patients with sensitivity and insight, and a measure of confidence. Interestingly I was recently informed that the topic of spiritual suffering and care has been introduced in the undergraduate medical curriculum of the University of Sydney, and I believe that South African programmes should follow suit. We now have a resource which paves the way.

Thank you!

Detlef Prozesky,

Director of the Centre for Health Science Education

Faculty of Health Sciences

University of the Witwatersrand

This address was subsequently published under the title "Spirituality as an element of health science education and practice" in the African Journal of Psychiatry 2009; 12:103-107.

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Annexure: Definitions

Agnosticism: Agnostics believe that it is impossible to know God's nature or even if he exists. This position of uncertainty implies a certain distance from religious matters and religious commitment.

Atheism: Atheists do not believe in the existence of God, gods, or other supernatural entities. Atheists believe that the existence of God cannot be scientifically proven and that His existence is refuted by the existence of evil.

Freethinkers: Freethinkers are people who form opinions about religion on the basis of reason; regardless of tradition, authority, or established belief. Freethinkers include atheists, agnostics and rationalists and regard faith as invalid.

Humanism: A humanist, in essence, is someone who tries to behave authentically without expecting any reward or punishment after death. Humanism is seen as a progressive life stance that affirms a person's ability to lead an ethical life.

Naturalism: Naturalists believe that all phenomena can be explained in terms of natural (as opposed to supernatural) causes and laws. Naturalism does not deny nor affirm the existence of God, but regards him as unnecessary in scientific investigation.

Secularism: Secularism teaches that behaviour should be based on reason and knowledge. It does not acknowledge divine guidance or interference and life is to be lived without supernatural hopes and fears.

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**Bibliography**

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D'Souza, R 2007. The importance of spirituality in medicine and its application to clinical practice. Medical Journal of Australia, 186. (www.mja.com.au/public/issues/)

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**About the Book, the Author and the Trust**

The Book: When the piglet Babe, in the movie with the same name, is entered by his owner for the sheepdog trials, he initially has problems gaining the cooperation of the sheep. After consulting a senior ewe on how to win their trust, he is told simply to ask nicely! He follows suit and the sheep perform flawlessly on the day of the trials.

It is certainly our wish that this book may become a guide to all healthcare professionals. Of course, we do not expect doctors and nurses to become walking encyclopedias of the do's and don'ts of the religious traditions in our country. However, if we learn from Babe, and observe the golden rule to simply ask nicely when, still, we do not know, we can go a long way in becoming sensitive to the spiritual needs of all recipients of health care.

The Author: Gerrie Lubbe retired as professor of Religious Studies at the University of South Africa, Pretoria. He was a founder member of the South African Chapter of the World Conference on Religion and Peace and served as its first president from 1984 to 1994. In 1992 he received the Indicator Human Rights Award for his contributions in the area of religious freedom. In 2003 he was awarded a Fulbright scholarship to study religion-state relations and religious diversity in the USA. He is currently chief executive officer of the Desmond Tutu Diversity Trust.

The Trust: With this publication, the Desmond Tutu Diversity Trust has taken a further step in the promotion of diversity awareness in South African society. Its other projects are:

The design of nine posters for the Department of Education in support of its new Policy on Religion Education. The posters depict the assessment standards for grades R to 3 and deal with symbols, important days, diet, clothing and decorations in seven religions. DoE printed 100, 000 sets of these posters and distributed them to schools countrywide.

A Youth Think Tank, which is designed to get young adults together across cultural and religious barriers. This project had a very important spin-off, when, in April 2008, Cook for Peace took place under our auspices. It involved 30 Jewish and 30 Muslim students cooking a meal together.

A Teachers Forum, where we aim to assist teachers in understanding and handling diversity in the classroom. The first phase consists of workshops for high school teachers in Gauteng. Our initiative has been met with great enthusiasm from the side of participants and of education authorities.

This book was previously published in two paperback editions. This electronic edition was edited by Michel Clasquin-Johnson. You can find his own publications at http://tinyurl.com/michelsbooks.

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