“Do You Believe In God?”: Caring for the Nonbeliever at the End of Life

Nonbelief appears to be on the rise. In 2012, “The Global Index of Religiosity and Atheism” found that the number of Americans who say they are “religious” dropped to 60%; it was 73% in 2005 when the poll was last conducted. In addition, 33% of polled persons did not consider themselves as being religious.

But what does it mean to be a non-religious person? A lot of terms are floating around out there classifying nonbelief—from secular humanism, to atheism, to agnosticism, just to name a few. And there’s lots of debate over what these terms truly mean and how people identify themselves as nonbelievers. So it was interesting to read a blog post on CNN about a new study that looked at this more closely.

The authors of the study—students at the University of Tennessee—interviewed 59 nonbelievers and identified at least six distinct types among them:

• Intellectual atheists/agnostics: These individuals were more scientifically minded and generally enjoyed debating the existence of a higher power. They also tended to be well read with regard to world religions and to have a good understanding of religious beliefs. Generally, it was this intimate understanding of religion that led to their nonbelief.
• Activists: This group felt compelled to convert others to atheism or agnosticism, generally by arguing that society would be a better place without religion. They also tended to focus their efforts on political and humanitarian causes, such as protecting the environment and ensuring marriage equality.
• Seeker-agnostics: This group wasn’t quite sure about whether or not a God exists, but they made a point to question and evaluate their beliefs. In general, these individuals asserted that the world is a mysterious place and that human knowledge is too limited to make a concrete determination regarding the existence of a higher power.
• Anti-theists: These individuals regularly spoke out against religion and religious beliefs, viewing such ideologies and practices as ignorant and dangerous. They believed their views to be superior, and at times became confrontational when defending or discussing them.
• Non-theists: These individuals didn’t involve themselves with either religion or anti-religion. Subsequently, they were viewed as apathetic or disinterested.
• Ritual atheists: Although these individuals didn't believe in God and tended to dismiss the possibility of an afterlife, they still found useful lessons in some religious traditions and doctrines. They viewed these doctrines more as philosophical teachings, rather than historic events. They also reported participating in some religious rituals, often because these were part of their family traditions.

According to the blog post, the authors of the study note that their “main observation is that nonbelief is an ontologically diverse community,” and they speculate that nonbelief may grow from a typology of the six types they identified to one of 32 types in another 30 years or so. Since nonbelief is on the rise, this is certainly plausible.

Of course, the study is limited by being so small. And there is likely a lot of overlap in the categories they already identified. But it did make me wonder about when differences between these categories truly become meaningful. To me, it seems the distinctions will take on increased significance at the end of life. For example, I could see a ritual agnostic wanting last rites because he or she views this as a comforting tradition, but an anti-theist viewing being subjected to such an act as an affront.

As nonbelief continues to gain traction, geriatricians and other healthcare providers will be caring for many more nonbelievers facing the end of life, and it appears that all of these patients cannot be pigeonholed into one broad category of nonbelief. Just as there are many religions with distinct ideologies and practices, much the same appears to be going on within the nonbelief movement. To me, the question then becomes “how will the healthcare community address this?” 

Currently, spiritual care services are a large focus in hospice and palliative care settings. This isn’t surprising since spirituality and religion have been intertwined with medicine throughout history. But as beliefs change, these services will no doubt have to adapt.

In 2011, we published “Try This: Assessment of Spirituality in Older Adults: FICA Spiritual History Tool” in Annals of Long-Term Care. This tip sheet attempts to help healthcare providers determine their patients’ religious and spiritual beliefs through a series of questions. The goal is to determine patients’ stance as a means of personalizing care to meet their psychological needs as they’re approaching death. Although this tool acknowledges that some patients may not have faith or spiritual beliefs, it remains religion-centric. And shortly after we ran this tip sheet, we received a Letter to the Editor from a doctor who pointed that out. He noted for us that some religious skeptics would be offended by the order of questions in this tool and the phrasing used. Looking it over again, I can see his point. And it’s clear to me that better assessment tools are needed to gauge patients’ needs at the end of life.

Religious or not, no one’s beliefs fit exactly the same mold. Therefore, perhaps the first question should be: “Do you believe in God?” If the response is “no,” maybe a tool focused on assessing the wishes of the nonbeliever is warranted. And if the response is “yes,” then other specialized assessment tools would be used to better determine those beliefs and needs. 

Would such an individualized approach be practical? Or should one definitive tool be developed? And who would develop this/these tools? We’d like to know your thoughts on these issues. We'd also like to know how you handle your patients’ beliefs when providing end-of-life care.