Originally published in Explore: The Journal of Science and Healing

The surgeon as priest, shaman, or healer performs sacred rituals every time he or she steps into the operating room.  The power of healing for both the surgeon and the patient is potentiated by the ceremony itself representative in the psyche of the participants; the altar and participants bathed in iconic blue opening the doors of perception to the spiritual significance of life.

Medical science originally evolved from religion and spirituality.¹  This statement seems conflicted with the general premise that spirituality holds no place in medical practice, and some have declared those bringing spirituality into medical practice are “quacks.”²  It is important to distinguish between religion and spirituality, with spirituality being more focused on individual growth, less formal, less authoritarian and orthodox, and more universalizing.^3(p66)  There is no doubt medicine and spirituality deal with personal suffering, and both of these paradigms attempt to simultaneously relieve suffering.   Spirituality and suffering are unique to the individual, and thus the hermeneutical aspect of suffering comes into play.  Studies have shown patients undergoing coronary artery bypass gain a new appreciation for life and health, and spirituality develops as an inner strength helping them navigate through suffering.⁴  If medicine has religion, spirituality, and ritual as it’s base then there is no place more sacred than the operating room.  The operating room is not a place often seen by many, and those who experience this arena as a patient see the process as detached from their own spiritual connections.  The purpose of this paper is to look at surgery, its preparation, consents, theater, and recovery as a spiritual process and look at the foundations of this process from the viewpoint of a sacred ritual.

Rituals in medicine can invoke an archaic sense of indigenous cultures and not the technologically superior theaters we see in hospitals today.  However, in an anthropological sense, ritual can be a transmission from illness to health; if patients and physicians can understand this connection it may improve the quality of care given to surgical patients and enhance recovery.⁵

The Ritual of Informed Consent

Ritual is the way you carry the presence of the sacred.
Ritual is the spark that must not go out
– Christina Baldwin

Informed consent is a process of communicating between patient and physician resulting in an authorization or agreement to undergo a specific healing intervention.⁶  There is a power in healing ritual, such as surgery, and some have attributed this power to the act of placebo⁷; if the patient is aware the ritual is for them they may heal simply through this knowledge.  A recent study of patients undergoing a placebo-controlled arthroscopic surgery showed similar success rates to patients actually undergoing the surgical procedure .⁸  This study shows the power of preoperative counseling, preparation for the ritual or procedure, and how the incision can have the power to heal when nothing surgically is performed.  In my own practice it is obvious the time spent in counseling the patient in the surgical process is the preparatory work of the ritual.  Instruction are given; no food or drink after midnight, no make-up or finger-nail polish, most medications should be held until after the surgery, and in some cases bowel preparation is recommended.  This preparatory work is treated as sacred and the surgery itself could be canceled if the directions are not followed exactly as prescribed.  Certain spiritual practices such as the Brazilian church Uniao do Vegetal will not allow members to participate in the sacramental plant rituals if they do not follow strict diets and abstain from certain behaviors.^{9(p 73)}  This process of preparation is what sets the tone for a sacred ritual.  The officiate or surgeon is giving sacred instruction to the patient based on knowledge handed down through the generations and the patient is absorbing the information on a level of trust and the interaction between the internal psyche and external archetypes; this type of interaction described by Buber¹⁰ as he depicted relationships living in the space between people; this space being sacred.  This verbal and emotional preparation gives way to the physicality of the surgery and thus one must come prepared to bring a sacred donation for the healing ritual.  We now move into preoperative labs and tests as part of the scared ritual.

Sacred Blood and Staving Off the Angry Gods

Christianity is haunted by the theory of a God with a craving for bloody sacrifices – J.B.S. Haldane

With informed consent finalized, the patient is ready for the preparation of the body.  In many instances this means blood and urine testing, and possibly radiographs or electroencephalograms.  A most sacred ritual, Christian Communion, one of the Seven Sacred Sacraments, participants voluntarily drink wine or juice as a vestige of Christ’s blood.  This ritual brings the congregation into a communion with themselves and Christ and reminds them of life, death, and resurrection.  This most sacred ritual involves symbolic blood of the Christian Savior because blood is a revered essence of life and death.  When Jesus gives his disciples the cup and says “drink from it all of you.  This is the blood of my covenant which is poured out for many for the forgiveness of sins” Matthew 26:26-28 (New International Version), blood is being utilized to signify life and for a cleansing of the spirit.  A blood sacrifice is asked of all preoperative patients in order to look at values and make sure the patient is physically prepared for the surgical process.  While more blood cells will be produced by the patient, during the procedure the patient will inevitably lose more blood to the procedure and thus donate additional sacrament to the process thus connecting the preoperative ritual to the surgical suite; connection providing continuity.  The importance of continuity in ritual is seen in the Kiowa Gourd Dance and how this ritualistic practice connects Kiowa Indians to their community.¹¹  A final piece of this preparatory work for the surgical suite is finding a time that is appropriate for both the surgeon and the patient.  Patients may wish to perform the surgery on an important date for them or during a time when they have an opening in a busy schedule.  The importance and sacredness of the time and dates selected is essential for the social support of the patient and expands their spiritual understanding of healing from a phenomenological perspective.^12(p2)

Fasting and the Naked Now

The best of all medicines is resting and fasting – Benjamin Franklin

The liminal space between surgery and the preoperative phase is bridged by the quiet of fasting.  Fasting also bridges religious worlds.  Along with prayer, study of sacred texts, family worship, and ordinances,¹³ fasting is a common spiritual practice for individuals setting a sacred space.  Preoperative fasting is geared towards reducing stomach acid and thus the likelihood of dangerous aspiration during surgery.¹⁴  The patient is asked to fast for eight to twelve hours prior to surgery and depending on the type of procedure they may be asked to eat a more restrictive diet for a more extended period of time.  Depending on the surgical site the patient may also be asked to refrain from intercourse or to clean and trim the area of any body hair.  The dietary restrictions are commonplace with scared rituals in indigenous practices.  For instance, in Vietnamese culture, women wishing to regain strength and vitality after childbirth while breastfeeding are asked to partake in a sacred ritual where they must adhere to a strict postnatal diet.¹⁵  The final process of the preoperative ritual and transition to the sacred space of the operating room is the patient removing all vestiges of the outside world.  Clothes, make-up, jewelry, nail polish and any other external fetishes are removed and placed in a bag in the preoperative unit.  The stage is important obviously because the patient will face the operating room in a naked supine fashion, and their given name is the only moniker of their identity.  This nakedness as a ritual is symbolic representation of both grave and womb.¹⁶  In this sense the patient enters the surgical suite one step closer to death surrounded by the technology of birth and nakedness of salvation.

Andreas Vesalius, 16th Century physician

The Origins of Counting and the Preparation of Space

Everything the power of the world does is in a circle – Nicholas Black Elk

Prior to escorting the patient to surgery, the surgical suite is prepared.  The air filters are sterilizing and purifying the air.  Sterile water and saline are poured into heated basins and the process of counting begins.  Trays of instruments are opened, and each has its sacred place on the operating room table.  Each surgeon has a card dictating what they like to have on this table for each particular ceremony and the scrub nurse prepares the table according to her specified ritual.  It’s important to see this as the beginning of a circle.  As each instrument, sponge, and needle is counted and subsequently used, the process will end according to these same sacred numbers.  If the numbers at the beginning and ending of the surgery do not match precisely then the surgery cannot end.  Sacred ceremonies also include purified water¹⁶ and the shaman or officiate will often carry a sacred bag filled with instruments of their trade.¹⁷  These bags carry special objects of power like eagle feathers or personal items infused with power, and they can be called many names like the muvieri in Huichol customs.  The muvieri itself is touched to all things owned by the healer and consecrated with blood as are all the tools placed inside.^18(p42)  The shaman will also carefully lay his or her items out on a special blanket and place them in a formation specific to their needs; they may be scraps of cloth or instruments but each is infused with power and necessary for the healing process.¹⁹  The point of preparation for a sacred process is that each item has its place.  The item may not be used, but it will go back to the bundle or back to central supply where it will be treated with spiritual sterility until needed again.  The final piece of surgical suite preparation is counting the instruments and sponges.  This process is so sacred it takes place three times during the surgery with the following criteria: those individuals counting must remain the same, counts must match each time, fatigue of participants is noted, and urgency of the procedure changes the manner in which items are counted.²⁰  Items are counted before, during, and at the end of the procedure, and may be one of the most revered parts of the surgical process.  With the surgical altar properly prepared, the patient is brought to the room in an altered state of consciousness; having been given a sedative prior to the transition; the patient must be altered prior to entering this sacred space. 

As the patient is ushered from transport bed to the operating table, he or she is placed upon a narrow table with their arms outstretched to the sides at ninety degree angles to the supine body; a position reflective of a religious crucifixion.  Similar to the nakedness mentioned earlier with its overtones of birth and death, the image of the crucifixion is emblematic of suffering ennobled and meaningful, and the promise of resurrection .^21(p745)  With the patient strapped to the table across their waist and pneumatic compression stockings on the calves, the anesthesiologist now begins the process of inducing the patient into general anesthesia.  A mask, or oxygenated fetish is placed over the patient’s mouth and nose, while the operating room attendants (also masked) quietly await the patient’s transition into this passive state.  In some spiritual ceremonies where the patient is clothed or possibly not present a naked fetish doll is exhibited during and prior to the ceremony to represent the individual being healed.²²  With the patient naked, exposed, masked, mentally altered, and strapped to a symbolic crucifix it is time to ceremoniously prepare and drape the subject and await the entry of the surgeon to the field.  With the patient, surgical technicians, and physicians masked we can move from this mere concealment and open psychological experience toward the spirits and archetypal gods of healing.^23(p722)

A World Draped in Blue – The World of the Healer

A blue surface seems to recede from us….it draws us after it – Goethe

The surgical drapes are blue.  The surgical caps and gowns are blue.  The scrubs are blue and blue is

linked with eternity, the beyond, supernatural beauty, religious transcendence, the spiritual and mental as contrasted with the emotional and physical and with detachment from the earthly.”^24(p650)

It may be unconscious, but the surgical process is donned in blue. While the patient is draped in blue covers and the surgical instruments are waiting on a blue sterile surgical field, the surgeon is outside cleansing his or her hands.  This scrubbing is obviously functional for antisepsis, but it also serves a ritual purpose.  As in baptism, physical cleansing has been a process of religious ceremonies for millennia.  In sacred ceremonies there is a connection between the physical purity and the moral purity of the ritual, in a sense a washing away of sins prior to the procedure.²⁵  Once the hands and forearms are cleansed, the surgeon and his or her assistant enter the room with hands held away from the body.  This process of entering the room with the patient prepared is synonymous with the surgeon preparing to enter the healing plane and the patient’s physical body.  Blue gowns are donned and the surgeon prepares to make an incision.  In one last effort to remind the healer of the physical body, a nurse in the room calls out the name of the patient and the procedure about to be performed. This naming of patient and procedure is called a “time out” in the operatory and is required by medical governing bodies, but it can also serve as a preparatory pause.²⁶  In the allopathic realm this “time out” is a means for the participants to unify in the right patient and the right surgery.  In a ritualistic sense this “preparatory pause” adds a level of mindfulness bringing the group affect to focus on the patient and the procedure at hand.  The theater is ready, the participants and patient are in place, and it is now time for the ritual to become active; a time for wound creation.

The Wounded Healer and the Sacred Wound

Conscience is an open wound, only truth will heal it – Usman Dan Fodio

The surgical wound is an obvious incision into the patient in order to explore the inner physical world and remove or heal damaged tissue.  Mythically, the wound as opening is also a gateway to potential transformation, and a window into encapsulated history.^27(p734)  In many instances the wound is created by a wounded healer or a surgeon that carries their own scars.  In my own mythology, through genograms, I discovered that all maternal relationships in my family are connected by conflict.  When I saw this conflict on paper I understood the reason I became a gynecologist was actually two-fold.  On one hand, I was being present at parturition bringing me closer to the maternal-fetal bond; a bond needing healing in my family.  The second and potentially sinister side of becoming a gynecologist was the need to surgically remove a women’s uterus.  It was through this maturation and discovery that I was able to become a better physician and wrestle with inner demons.   In ritualistic indigenous cultures, the first stage to becoming a healer, as described by,²⁸ is that of the calling; this call comes from the family, community, or from world beyond. Shamans are called, and then receive rigorous instruction, followed by initiation and practice. Allopathic physicians have similar stages of development: the call to be a physician, followed by the structured education of medical school, the initiation of residency, and ultimately the practice of medicine in the community.²⁹  The wounded healer may have emotional, physical, or mental challenges that result in a spiritual insight or awareness that comes once they have surrendered to their wounds; these wounds become part of the medicine bundle, surgical table, and a tools of the surgeon.  Wounds are an essential piece of the healing ceremony, because without wounds there would be no reason to heal.  The ritual of an operation commences, before, sometimes long before the incision is made, and may continue for a long period after the wound is healed.^30(p27)  In between the beginning and end points of the ritual is the spiritual process of entering another’s physical body.  This spiritual process of knowing the patient as a person builds a phenomenological bond between care provider and patient increasing patient advocacy when they are incapacitated.³¹  Conclusively, experiencing the patient externally and internally is the basis for this person-centered ritual or surgery, and continuity of care is essential for ongoing psychological support form a hermeneutical perspective.³²  A point well recognized in the ritual of surgery is on liminality with the patient in an altered state of consciousness.  Consummation of the ritual is during the patient’s resurrection.

Surgical Resurrection and Ritualistic Awakening

Every parting gives a foretaste of death, every reunion a hint of the resurrection– Arthur Schopenhauer

Some cultures utilize entheogens during ritualistic practice as a form of spiritual communication and unction.  It has been shown in these cultures that psychological assessments after these entheogenic inductions participants recount feelings of increased assertiveness, serenity, and joy.³³ Similarly, postoperative patients will report increased emotional distress post-surgery, especially if there were longstanding emotional problems prior to the case.³⁴ Many rituals, like high school graduation, will have processions into and out of the ceremony.  The ceremonial procession is an act of transition in an orderly succession.³⁵  In the surgical ceremony there is a procession from the death to the awakening or resurrection of the patient who is now altered not only by anesthetics, but physically as well; this physical alteration permanently scarring the patient.is seen in many cultural rites of passage.  With the patient awakened now to the healing process, the succession reverses and the patient leaves the operating room as she entered.  The bed is wheeled feet first towards the preoperative unit and her eventual recovery.  The surgical process as a sacred ritual is a passage from death into a newly resurrected state; a glimpse of the impermanent state of health as our bodies continue to age.

Conclusion

Too much has been said about physicians acting out God-like complexes and their inability to communicate with patients.  In many instances this may be true, but it is also undeniable the surgeon holds an awesome and awe-inspiring potential to heal.  A portion of this process is through the sacred ceremony of surgery itself.  Hall³⁶ suggests there is something priestly about the surgeon with his table being his altar, yet priests have more a religious connotation and thus may negate the spiritual aspects of secular surgery. 

Informed consent and counseling begins the patient on the heroes’ quest of discovering health.  This brings the patient into a more active role and demands their participation in the approaching ceremony.  This will not be a passive healing process, but will ask the patient for blood and bodily fluids as consecration in the healing process.  Further connection of the patient to the ritual is the fasting process and the preparation of the body to receive the healing.  Presentation of the patient in a naked supine posture is symbolic of their naked birth and the vast potential of their human condition.  There is also the symbolism of death as the patient is placed naked on the altar of the operating room table in the crucifixion pose; this signifying their eventual resurrection and rebirth from the surgical theater.  Sacred counting is performed to provide continuity and patterning during the ceremony and the instruments are specific to each healer as well as the positioning of the instruments on the table.  Eventually, the patient is brought out of the operatory and ceremoniously carted back from whence they started. 

The surgeon as priest, shaman, or healer performs sacred rituals every time he or she steps into the operating room.  The power of healing for both the surgeon and the patient is potentiated by the ceremony itself representative in the psyche of the participants; the altar and participants bathed in iconic blue opening the doors of perception to the spiritual significance of life.

References

1. Modjarrad K. Medicine and spirituality. JAMA 2004;291

2. Block M. Allopathic or allopathetic medicine? The impact of non-evidence based disciplines on allopathic medicine. AzMedicine 2008;18:8–9.

3. Ravenscroft P, Ravenscroft E. Spirituality and surgery. In: Dunn GP, Johnson AG, eds. Surgical Palliative Care. Oxford, UK: Oxford University Press; 2004:65–84.

4. Britt Raholm M. Weaving the fabric of spirituality as experienced by patients who have undergone a coronary artery bypass. J Holist Nurs 2002;20:31–47.

5. Wall LL. Ritual meaning in surgery. Obstet Gynecol 1996;88:633–637.

6. American Medical Association. Informed consent. Available at: http://www.ama-assn.org/ama/pub/physician-resources/legal-topics/patient-physician-relationship-topics/informed-consent.page. Accessed October 1, 2011.

7. Kaptchuck TJ. The placebo effect in alternative medicine: can the performance of a healing ritual have clinical significance. Ann Intern Med 2002;136:817–825.

8. Moseley JB, O’Malley K, Petersen NJ et al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med 2002;347:81–88.

9. Grob CS. The psychology of ayahuasca. In: Metzner R, ed. Sacred Vine of Spirits: Ayahuasca. Rochester, VT: Park Street Press; 2006:63–94.

10. Buber M. I and Thou (W. Kaufmann, Trans.). First Touchstone Edition ed. New York, NY: Free Press; 1971.

11. Kracht BR. Kiowa powwows: continuity in ritual practice. Am Indian Q 1994;18:321–348.

12. Csordas T. The Sacred Self: A Cultural Phenomenology of Charismatic Healing. Los Angeles, CA: University of California Press; 1994.

13. Marks L. Sacred practices in highly religious families: Christian, Jewish, Mormon, and Muslim perspectives. Fam Process 2004;43:217–231.

14. Brady M, Kinn S, Stuart P. Preoperative fasting for adults to prevent perioperative complications. Cochrane Database Syst Rev 2003;(4):CD004423.

15. Rossiter JC, Yam BM. Breastfeeding: how could it be enhanced? The perceptions of Vietnamese women in Sydney, Australia. J Midwifery Women’s Health 2000;45:271–276.

16. Turner V. The Ritual Process: Structure and Anti-Structure. Reprint ed. Piscataway, NJ: Aldine Transaction; 1995.

17. Miller Van Blerkom L. Clown doctors: Shaman healers of Western medicine. Med Anthropol Q 1995;9:462–475.

18. Endredy J. Lightning in My Blood: A Journey into Shamanic Healing & the Supernatural. Woodbury, MN: Llewellyn Publications; 2011.

19. Thomas SJ. The Sioux medicine bundle. Am Anthropol 1941;43:605–609.

20. Gawande AA, Studdert DM, Orav EJ, Brennan TA, Zinner MJ. Risk factors for retained instruments and sponges after surgery. N Engl J Med 2003;348:229–235.

21. The Archive for Research in Archetypal Symbols (ARAS). Crucifixion. In: Ronnberg A, Martin K, eds. The Book of Symbols. Los Angeles, CA: Taschen; 2010

22. Sargant W. Witch doctoring, zar, and voodoo: their relation to modern psychiatric treatments. Proc R Soc Med 1967;60:1055–1060.

23. The Archive for Research in Archetypal Symbols (ARAS). Mask. In: Ronnberg A, Martin K, eds. The Book of Symbols. Los Angeles, CA: Taschen; 2010:

24. The Archive for Research in Archetypal Symbols (ARAS). Blue. In: Ronnberg A, Martin K, eds. The Book of Symbols. Los Angeles, CA: Taschen; 2010:

25. Zhong C, Lijenquist K. Washing away your sins: threatened morality and physical cleansing. Science 2006;313:1451–1452.

26. Backster A, Teo A, Swift M, Polk HC, Harken AH. Transforming the surgical “time out” into a comprehensive “preparatory pause”. J Card Surg 2007;22:410–416.

27. The Archive for Research in Archetypal Symbols (ARAS). Wound. In: Ronnberg A, Martin K, eds. The Book of Symbols. Los Angeles, CA: Taschen; 2010:

28. Eliade M. Shamanism: Archaic Techniques of Ecstasy. New York, NY: Pantheon Books; 1964.

29. Tassone SA. Medical materialism, shamanic healing, and the allopathic paradigm. Available at: http://www.realitysandwich.com/blog/7396. Accessed January 29, 2009.

30. Moynihan BG. The ritual of a surgical operation. Br J Surg 1920;8:27–35.

31. Tanner CA, Benner P, Chesla C, Gordon DR. The phenomenology of knowing the patient. J Nurs Scholarsh 1993;25:273–280.

32. Gilmartin J, Wright K. Day surgery: patients’ felt abandoned during the preoperative visit. J Clin Nurs 2008;17:2418–2425.

33. Ribiero PC, Giglio JS, Dalgalarrondo P. Altered states of consciousness and short-term psychological after-effects induced by first time ritual use of ayahuasca in an urban context in Brazil. J Psychoactive Drugs 2005;37:193–201.

34. Kimball CP. Psychological responses to the experience of open heart surgery. Am J Psychiatry 1969;126:348–359.

35. Boesky D. The psychoanalytic process and its components. Psychoanal Q 1990;59:550–584.

36. Hall DE. Altar and table: a phenomenology of the surgeon-priest. Yale J Biol Med 2008;81:193–198.