Does a Multi-Dimensional Concept of Health Include Spirituality? Analysis of Japan Health Science Council’s Discussionson WHO’s ‘Definition of Health’ (1998)

The Health Science Council of Japan proposed to include the term ‘spirituality’ in W HO’s ‘defin ition of health’ over three meetings. However, no consensus on the proposal was achieved. This study uses the minutes of the meet ings to explore the members’ implicit understanding of ‘health’, varied interpretations of ‘spirituality’, and reservations against the inclusion of ‘spirituality’ in the official defin ition of health. By analyzing the Japanese perspective on the subject, this study seeks to contribute to the conceptual defin ition of ‘health’ and elucidate the challenges involved in incorporating ‘spirituality’ as a dimension of health in the field of contemporary medical care.


Introduction
In 1999, the field of Japanese medical care witnessed a sharp increase in the number of academic publications on spirituality [1]. Possibly, the increased focus on spirituality stemmed fro m the p roposal, submitted between 1998 and 1999, to revise the 'definition of health' by including the aspect of spirituality in the preamble to the World Health Organization (WHO)'s Charter. A rev ision in the definition was proposed at the 101st session of the WHO Executive Board by the WHO Regional Office for the Eastern Mediterranean, wh ich included members fro m Islamic member countries. The proposal sought to modify the definit ion of health by adding the underlined wo rd as follows: 'Health is a dynamic state of co mplete physical, mental, spiritual, and social well-being and not merely the absence of disease or infirmity' [2].
Although many Japanese people participate in relig ious ceremonies that include weddings, births, funerals and New Year p rayers, there is a little sense of affiliation to any specific religious organization.Accordingly, there are many who consider themselves 'not relig ious', and according to a survey conducted by a leading Japanese newspaper [3], 76% 'do not believe in any religion'. On the other hand, 94% have a deep feeling of reverence towards their ancestors and 56% 'sense something in nature that surpasses the power of arrive at a consensus on the differences between the words 'mental' and 'spiritual'. Th is lack of consensus is said to have contributed to Nakamura's stand at the WHA52 subcommittee.
To date, there only exists a tacit acceptance of the notion of spiritual well-being within the conceptual dimensions of 'health' in the field o f nursing and welfare in Japan. The true notion of spirituality and the challenges of incorporating it in the official defin itions of health within contemporary medical care are yet to be fully explo red. This study attempts to address this gap through a retrospective analysis of the reasons that contributed to the disagreement among co mmittee members of the Health Science Council over the inclusion of spirituality in the definit ion of health. Unlike earlier studies that summarized the views of the officials of Health Science Council, this study seeks to provide a detailed review of the proceedings by using the minutes of the meet ing as investigative data. It answers questions such as who were the attendees at the deliberation council, what were their views, and how they were put forward and, more impo rtantly, what were the themes of conflict. By analy zing Japan's perspective on health and spirituality through the minutes of the Health Science Council's deliberat ions, this study sheds light on the current challenges in defining health as well the relationship between modern med icine and spirituality.

Methods
As mentioned earlier, the minutes of the meeting of the Health Science Council of the Former Min istry of Health and Welfare that discussed the proposal to add spirituality to WHO's 'defin ition of health' were analyzed. Specifically, these minutes included records of three meetings: A. The 6th general meeting of the Health Science Council (March 19, 1999), B. The 14th meet ing of the Health Science Council's Research and Planning Co mmittee (April 12, 1999), and C.The 15th meeting of the Health Science Council's Research and Planning Co mmittee (April 19, 1999). The total number of attendees at each meeting and their do mains of expertise are listed in Table 1. Excluding the Chairperson and overlapping participants, the number of committee members at each meeting was 21. Most of the attendees were experts fro m the field of natural sciences, w hile th r ee b elo ng ed to no n-s cien ce dis ciplin es. Throughout the three meetings, there were a total of 27 attendees-more than 80% o f the whole members. One of these members, who was an author, stated she was a Christian, but the religion of other members was unknown.
The reasons for disagreement on the issue of including spiritual dimension in the 'defin ition o f health' are examined fro m two perspectives. The first exp lores the framework that governed the committee's discussions of the term 'health'. The second perspective investigates discussions related to how 'health' should be defined using this framework as an imp licit premise and whether or not spirituality should be included in the WHO's 'definit ion of health'. In line with the standard methods of qualitative analysis ( [8], [9]), the recorded minutes were carefully interpreted, keeping in mind the perspectives of analysis. That is, by contextualizing the key points raised by each committee member within the scope of the analysis, the material was divided into themes. The minutes of all the three meetings were subjected to this process of interpretation. Existing themes were co mpared and contrasted with new data to continuously refine the interpretations. It must be mentioned here that the council members did not follow a question-and-answer approach to express their op inions on the proposal to add spirituality to WHO's 'definition of health'. Thus, for a co mplete understanding of the motivations behind their opinions, this study not only considers the actual words spoken by the council members but also the before-and-after contexts in which these comments were made.
Of the three meeting records, the minutes of Meeting B contained most of the discussions relevant to the subject of amending WHO's definit ion of health. It is likely that the presence of two members fro m the field of bioethics at Meeting B enabled a mo re detailed examination of the concept of spirituality. At Meeting A, co mmittee members were only invited to share their opinions on the proposal, whereas, at Meeting C, which was held a week after Meeting B, the proceedings did not proceed beyond a call for new ideas or opinions on the matter.

Framework for Discussing 'Health'
The framework or the implicit premise of the d iscussions reflected in the council members' co mments seemed to recognize hu man existence to belong to the realms of 'nature' and 'culture'. Th is view o f hu man existence, characterized by the dichotomy of 'nature' and 'culture', is consistent with the outlook of modern and Western societies, as highlighted by Latour [10]. According to the modern view, 'nature' represents the objective world, and is also the subject of scientific study, such as medical science. In relation to human existence, it refers to the physical and mental facult ies. 'Culture', on the other hand, denotes the subjective and relative world that is devoid of object ivity. It is "something artificial which only becomes constructible by bracketing out nature" [10]. In modern society, it includes religion, faith and its variants (e.g. spirituality), and is not a constituent of natural sciences.
Although there are no explicit references to this framework in the minutes of the meetings, the council members did not voice any clear opposition to this framework either. This suggests that the dichotomy between nature and culture was a shared knowledge among the committee members. That is, the meanings of the co mments were 'understood' when each co mment was perceived through this framework. For instance, one of the council members made the following comment on spirituality: This comment was rooted in the view that 'spiritual' belongs to the realm o f 'cu lture' while 'mental' belongs to the realm of 'nature'. In other words, the council member felt that spirituality should not be included within the definition of 'health' because he perceived 'health' as a matter that only belonged to the realm of 'nature'. The above point was developed further with the following argu ment fro m another council member: When thinking about health and medical care or when thinking about human existence…there is really no such thing as a person without a spirit. If you accept someone's existence as human-irrespective of whether or not you're speaking in religious terms-as long as someone exists as a human, they have a spirit. This position should form the premise. The idea that human beings have a spiritual existence is the context for this…I believe that the fundamental position is that spirituality exists within each and every human being.
This comment is also based on the modern view that recognizes the realms 'nature' and 'cu lture' in hu man existence. However, unlike the earlier one, this comment seeks to assert that 'health' is related to 'culture' and not separated fro m it.

Perceiving 'Health'
Three broad lines of argu ment could be identified in the responses to the question of whether 'health' belongs within the realm of 'nature' or 'culture'. First, three co mmittee members supported the first argu ment that 'health' only belongs within the realm of 'nature' and falls within the purview of med ical science. Second, two co mmittee members believed that the answer to whether 'health' belongs to the realm o f 'cu lture' is dependent on historical and social constructs. Finally, four co mmittee members argued that 'health' does belong to the realm of 'culture'.
Criticizing the move to include 'spirituality' with in the definit ion of 'health', the first group of co mmittee members explained that the term 'spirituality' did not apply to the natural sciences. They viewed 'health' as 'a question of science' and considered 'spirituality' on par with physical and mental states: They also argued that only med ical doctors can ascertain a person's health and that the definition should not prevent doctors fro m making this judgement: In medical care, the word 'health' is already used in a variety of contexts. If we do this[add a 'spiritual' dimension to 'health'] I feel that it will lead to many problems and much confusion. For example, i f language such as spiritual, religious or incorporeal is included in the definition of health, then judgements will be very difficult to make… and then you have health status reports carried out for employment and the like and you get the same thing with university entrance exams… I'm concerned that doctors will end up being unable to write such reports using their own judgement.
Two co mmittee members argued that the question of inclusion of 'spirituality' in 'health' depended on the relationship between the state and religion as well as between science and relig ion. In states that have adopted a religion, 'health' is included within the do main of 'culture'. The following comment illustrates this argument: Take, for example, the case of Islam. The idea of clearly separating politics and religion or clearly separating the activities of the state and the activities of religion is much more of a Christian way of thinking. When it comes to Islam, the idea of seeing the activities of the state and the activities of religion or secular activities and religious activities as part of a whole is very deep rooted. Therefore, i f you approach this issue from an Islamic point of view, you have, in a sense, a religious outlook where religiosity and secularity are so closely knit that you could even say that a concept of 'health' that excludes religiosity is in fact not even health in the true sense.
This view suggests that differences in the defin ition of health could be based on the relig ious and political beliefs of countries. For instance, while contemporary Christian states distinguish between politics and religion, Islamic states do not follow this practice. As a result, in Islamic states, a definit ion of 'health' that is devoid of spirituality would be unacceptable. In fact, even in Ch ristian states until the mid-n ineteenth century, the notion of spirituality was embedded in concept of 'health', as suggested in the comment belo w: With regard to the idea including 'spiritual' in relation to 'mental'… In traditional medicine, there was hardly any difference between the religious concept of 'healing' and the objective concept of 'medical treatment', for example, the concept of 'health' as an assessment of preventive effects.…Speaking in terms of cultural history, even in Europe, the concept of 'health' and the religious concept of 'healing' were closely linked up until the mid-nineteenth century.
This comment indicates that the subject of health and spirituality is also dependent on history. With regard to historical relativ ity, committee members also stated that 'in the past, the prevailing attitude in med ical care and science contained, in a sense, a subjective element that aimed to view human nature as a whole'; however, with the development of science and increase in environ mental dangers, 'there has been a shift towards a more negative as well as mo re objective view that seeks to identify such latent dangers against "health"'. Moreover, in the course of develop ment, modern medical science has also rid itself of all aspects that belonged to the realm of 'culture'.

If you think about the significance of adding this [spirituality] to the definition of 'health', on the positive side, if you perceive 'health' as an individualistic way of life and well-being in every sense of the word, incorporating 'spirituality' within 'health' has great significance. However, in the process evolution… modern medical science evolved by eliminating the spiritual aspects of health…
Four committee members argued that 'health' is related to the realm of 'cu lture'. In support of this argument, a member opined that the notion of spirit is synonymous with hu man existence and that the concept of healing includes a religious dimension. The member also said that there are aspects to 'health' that cannot be classified on the basis of mental and physical perspectives and relate to the realm of 'culture' at large and spirituality in particular. In light of the widespread deliberations on spirituality at the international level, the Council members wanted Japan to play an active role in furthering the dialogue on the relationship between 'health' and spirituality: It's not only in the field of health, but also in the economic development plans of the World Bank … the question of spirituality and the question of economic development in developing countries -such questions were issues were not addressed in the past, but they now represent an emerging theme. Within Islamic societies in particular, health and spirituality will become an even greater issue in the future and this issue will crop up not only in connection with health but also in connection with economic or developmental issues… and in particular with ideas such as Health For All In The Year 2000 (W.H.O). We are in an age where our lives are connected with the rest of the world and this world is looking to consider spirituality anew. The world as it is now has presented us with a challenge and how we respond to it is vital. If 'we are who we are', irrespective of the external changes, Japan will become more and more isolated and will not be able sustain its foothold as a member o f the international community….
Co mments were also made to support the view that 'health' is not only a subject of science (medical science): Whether a person is healthy or not will be established according to how spirituality is translated[into medical terms]. The term 'spiritual' must not be understood as faith or inspiration. The term 'mental' is associated with psychiatrists while the term 'spirit' refers to things like will and morale. One should question whether these are in the right shape… Therefore 'mental' faculties can be evaluated medically, but issues of the heart and soul, which must be judged in the social context, are worldwide issues. This means that the word 'spirit' is a significant issue.

Link between Commi ttee Members' Position on the Proposal and Their Area of Expertise
It is likely that committee's members varying responses to 'health', 'spirituality' and whether 'spirituality' should be added to the WHO's 'definit ion of health' were influenced by different factors. To exp lore if their do mains of expertise had an effect on the council's final decision to reject the proposal, the study explo red the correlation between the content of each co mmittee member's co mments and his or her field of expert ise.
Of 18 members whose academic expertise lay in the field of natural sciences, six members (33.4%) offered co mments on how to perceive 'health'. Not only did they offer different perspectives on health, their stand on the proposal to include spirituality also varied (Table 2). However, of the five members who opposed the proposal to include 'spirituality' in the W HO's 'definit ion of health', four specialized in med ical science.
All the three co mmittee members specializing in non-science fields felt that 'health' was embedded in the realm of 'culture'. However, their stand on the proposal depended on whether or not they perceived 'health' as historically and socially relat ive. Surprisingly, members who perceived health as being historically and culturally relative were against the proposal. This was because they believed that the WHO definit ion of 'health' should be based on objective standards and that identifying the minimu m standards for 'health' would be beneficial for the citizens of developing countries. The following comment expresses this view: In the so-called developing world in particular … a concept of 'health' that includes a higher class of spirituality will give rise to the idea that scientific concepts of 'health' are insufficient, and there is a possibility that this will lead to, in a sense, rather risky outcomes. I would say that using a slightly more objective standard as the international yardstick would be profitable in a number of ways.
Members also voiced the concern that physical and mental c ar e m ay b e c o mp ro mis ed as a r es ult of i nclu din g spirituality : One of the problems you'd face if you added spirituality would be the possibility that medical care and healing needs, in a certain sense of the word, would be considered fulfilled as long as attention is paid to the aspect of spirituality even if it implies insufficient mental and physical care… If 'medical care' is defined as something that aims to restore health and then 'health' contains 'spiritual' in its definition, then that is indeed a possibility.  Thus, even members that acknowledged the spiritual aspects of 'health' were not in favor of including 'spirituality' in the WHO defin ition because they believed that the WHO 'defin ition of health' should represent the minimu m standards to be met by all countries around the world. On ly two members were in the favor, arguing that 'health' includes the realm of 'culture', which is shaped by the society and time. Their assertion is in agreement with the view that health care, which involves making judg ments on 'health', is not only exclusively under the jurisdiction of med ical science or doctors who study it. The three dominant views exp ressed by different members are shown in Figure 1.
It is interesting to note that most of the members who unanimously decided to exclude 'spirituality' fro m the WHO definit ion belonged to the field of medicine. In fact, Eiichi Nakamu ra, who represented Japan at the subcommittee meet ing that decided against discussing the proposal at the WHA52, also specialized in the field of natural sciences. Predictably, the council members who supported the proposal to amend the WHO defin ition of health were fro m non-medical fields. Thus, it appears that domain expertise e xerted a moderate influence over council members' position on the proposal.

Discussion: The Positioning of Spirituality in WHO's 'Definition of Health' and the Challenges Involved
Members of the Health Science Council held d ifferent views on 'spirituality' and how it was positioned in the definit ion of health and disease. First, those who perceived 'health' as belonging exclusively to the realm o f 'nature' were medical scientists. They believed that 'health' is a subject of science (medical science) and that only medical doctors are suited to offer judgments on its state [11]. Second, the committee members who believed that history and society influenced the question of 'health' belonging to the realm of 'culture' also co mprised medical scientists. While these members recognized the spiritual aspects of health, they were not in favor of adding 'spirituality' to the definit ion of health. Lastly, the group who felt that 'culture' is universally embedded in the 'definit ion of health' did not consist of medical scientists. This group not only supported the proposal to add 'spirituality' to the defin ition of health but also believed that the subject of modern health care and spirituality required careful deliberation. It is reasonable to consider that the discrepancy in the views on the proposal could be attributed to whether members perceived 'health' (1) as something that belongs exclusively to the realm of 'nature', (2) as a component of culture that is influenced by history and society, or (3) as universally belonging to the realm of 'culture' (Figure 1).
An analysis of the number of co mments vis-à-vis the number of attendees at the three deliberation meetings of the Health Science Council offers interesting insights. Of the total 21 co mmittee members, n ine members did not comment on the issue ( Table 2). Most of them were experts in the natural sciences, and seven out of nine were medical scientists. Of the nine experts in the natural sciences who commented on the subject, six spoke about the defin ition of spirituality, seven discussed the relationship between areas of human existence and 'health', and six members exp ressed their opinions on whether or not 'spirituality' should be added to the definition of health. All three experts who did not belong to the fields of natural sciences commented on both the definition of spirituality and the relationship between the areas of human existence and 'health'. Two of these members shared their views on the proposal.
Members whose area of expertise lay in the natural sciences offered fewer co mments and personal opinions than experts fro m outside the natural sciences. In particular, there was a scarcity of co mments fro m med ical scientists on topic of human existence and 'health'. Why did some members who participated in the meet ingsdid not comment? The answer could possibly lie in the challenges that medical scientists face in speaking positively about 'health'. Clin ically diagnosed diseases, their symptoms, and treatments are well known to the medical fraternity, and e xperts fro m the field of med icine can usually speak eloquently on such matters. However, 'health' represents an absence of these diseases and is possibly viewed as a residual concept. Therefore, it is likely in contexts where 'health' is defined as something positive, medical experts lack the vocabulary to express the views.
'Health' is also a normative concept that is amendable [11] and continues to undergo changes [12]. For medical scientists, 'health' is a normative model used to biologically evaluate whether a physical or mental condition is normal or pathologic. On the other hand, people can lead 'healthy' lives even while suffering fro m disease or disability.
Canguilhem [13] explains that a person who has adopted a normative model of liv ing is beyond normal in that he or she responds adequately to his or her environ ment. Thus, the concept of 'health' is dynamic and varies according to time, society, and individual values. Hence, it is not possible to view 'health' as belonging to the realm of 'nature' alone.
The WHO definit ion of health has not been revised and the necessity of a revision was not recognized in the discussions that took place in the Min istry of Health, Labour and Welfare, wh ich has jurisdiction over Japan's health care system and the health of Japanese citizens. In spite of this, there have been increasing number of textbooks in Japan on health care, nursing care, and welfare that discuss the presence of a spiritual d imension in 'health'.
When viewed as a dynamic concept, 'health' is not only a reflection of individual values but also an outcome of the ju xtaposition of people's diverse values. This concept of 'health' possibly explains the conflicting views of the members of the Health Science Council and Japan's subsequent decision to postpone deliberations on including 'spirituality' as a dimension of health. The process whereby the members agreed to disagree on the proposal is surely an accurate reflection of the challenges involved in debating the position of 'spirituality' and in the process whereby 'health' is interpreted as a dynamic concept through linguistic activities and dialogue.

Conclusions
Although the Japanese people do not generally have a sense of affiliation to any specific religious organization, they do hold in co mmon a deep reverence towards forces that transcend human understanding. On the other hand, modern medicine has developed outside the domain of spirituality. Th is relates to the fact that modern science developed with a clear separation between 'nature' and 'culture'. In recent years, there has been an increasing interest towards spirituality in health care settings throughout Japan and the concept of spiritual health is also being discussed. However, medical doctors who contributed to the discussion on the WHO 'defin ition of health' argued that the concept of 'health' belongs to the domain of natural science and should be kept apart fro m the do main of cu lture. In other words, in order to define health as a whole concept rather than as a framework in modern science, there needs to be a paradigm shift amongst medical scientists and other natural scientists so that 'health' can be considered separately from the issue on 'the presence or absence of disease'.