Association of Art & Science Rome, ITALY

SPIRITUALITY:

 


Faith and Healing
Annals of Internal Medicine, 18 January 2000.
Linda Gundersen


Studies suggesting that church going, religious beliefs, and prayer can improve morbidity and mortality have increasingly received attention in medical journals and the general media. One study at Duke University concluded that steady church attendance improves health and prolongs life (J Gerontol A Biol Sci Med Sci. 1999;54:M370-6). Some authorities, however, believe that researchers often use flawed methods to study the relation between health and religion. They point out that the cause-and-effect relations are frequently unclear because religious persons, who are often defined as regular attendees of worship services, are in general already healthier than nonreligious persons. In fact, several studies that report the beneficial effects of religion do not adequately adjust for health behaviors or sociodemographic factors, thereby casting substantial doubt on their conclusions.
However, some studies of intercessory prayer and some studies that accounted for baseline health and other variables have produced a modest amount of evidence that links religiosity with improved health. Experts are divided: Many cannot explain these results, and others continue to debate the possibility that a connection exists at all. Hundreds of years ago, medicine and religion were almost synonymous; in recent years, however, they have been almost completely separate. Emerging controversy surrounds the ways in which physicians should respond to this renewed tendency to link the two domains.


Religious Practice and Health
It is important to distinguish between religiosity and spirituality. Harold G. Koenig, MD, MHSc, lead author of the Duke University study and associate professor at Duke University Medical School, points out that most studies assess religiosity rather than spirituality because religiosity is easier to measure. Dale A. Matthews, MD, author of The Faith Factor, a recent book on religion and health, defines religiosity as a person's adherence to the beliefs and practices of organized religion. Only a few studies have focused on spirituality, which is much more difficult to gauge; Matthews defines it as a person's search for meaning or for a personal relationship with a higher power. Studies of religion's effect on health often assess religiosity by determining frequency of attendance at worship services. This can be easily measured; persons' perceptions of their relationships with a higher power cannot.
The Duke University study used church and synagogue attendance as a measure of religiosity. Baseline assessment included additional health variables. During a 6-year period, researchers studied 3968 residents of northern California who were 64 to 101 years of age. At follow-up, 29.7% of the participants had died. The relative hazard of dying was 46% lower for those who attended religious services frequently (at least once per week) than for those who attended services infrequently. Even after such significant variables as number and type of comorbid conditions and amount of socialization were excluded, the mortality rate of churchgoers was 28% lower than that of persons who did not go to church.
Another study that used attendance of religious services as a gauge of religiosity was conducted over a 28-year period in 5286 residents of Alameda County, California (Am J Public Health. 1997;87:957-61). In that study, Strawbridge and colleagues found that the mortality rate was lower in persons who frequently attended religious services than in those who attended infrequently. The authors concluded that at least part of religion's effect on the mortality rate could be attributed to the fact that frequent attendees had less exposure to certain risk factors for hastened death (for example, smoking, alcohol use, and limited social contacts).


Prayer and Spirituality
In a study by Harris and coworkers (Arch Intern Med. 1999;159: 2273-8), attendance of worship services was not included in the methods. The authors studied 990 patients who were admitted consecutively to a coronary care unit and were randomly assigned to receive intercessory prayer for 4 weeks. The patients did not know that the prayers were being offered, and the intercessors knew only the first names of the patients. Although length of hospital stay did not differ between the prayer and nonprayer group, the patients who received remote intercessory prayer had lower coronary care unit severity "scores." Critics of this study's findings point out, however, that the authors used a flawed method to randomly assign patients to study groups and that the method used to score severity was not validated.
Warfield and Goldstein (Counseling and Values. 1996;40:196-205) did not examine religion and intercessory prayer but focused only on the effect of spirituality as a treatment aid in patients with alcoholism. They reviewed literature on Alcoholics Anonymous, the first known 12-step program, and found that Alcoholics Anonymous, the book that laid out the premise of the program and acted as a springboard for other 12-step programs that followed it, suggests that alcoholics "may be suffering from an illness which only a spiritual experience will conquer" (Alcoholics Anonymous. 3rd ed. New York: Alcoholics Anonymous World Services, Inc.;1976:44). The authors aimed to discern the importance of the spiritual aspect of Alcoholics Anonymous and concluded that a "spiritual awakening" is vital to recovery from alcoholism.


"If" and "Why": The Debate
Many studies, whether they measure the effects of religion, intercessory prayer, or spirituality, have been refuted by experts who dismiss the results as negligible. Richard Sloan, PhD, from the Behavioral Medicine Program at Columbia-Presbyterian Medical Center, the Department of Psychiatry at Columbia University, and the New York State Psychiatric Institute, says that after the confounding variables are removed from these studies, the results almost always are statistically insignificant. In an article in The Lancet (1999;353: 664-67), Sloan and others contest the findings of several studies. Colantonio and colleagues (Am J Epidemiol. 1992;163:884-94) found that rates of stroke were lower in persons who attended a religious service at least once per week than in those who did not attend at all. Sloan and colleagues noted that after differing levels of physical function were taken into consideration, the relation between stroke and attendance at religious services was no longer statistically significant. A study by Pressman and colleagues (Am J Psychiatry. 1990; 174:758-60) found that the ambulatory status of religious elderly women who had surgery on broken hips was improved at discharge. Sloan and colleagues believe that the results of this study are unconvincing because the authors did not control for one critical variableŅage.
Koenig believes that some variables should not be discarded, such as the fact that churchgoers are in relatively better health than persons who do not go to church because of a lower smoking rate and other health factors. "If you controlled for those factors and you find the relationship goes away, you simply controlled for the mechanism of the effect. That doesn't diminish the effect of religious involvement on the health outcome-it simply explains it," he stated. Sloan does not dispute Koenig's statement, but adds that many positive behavior mechanisms are often unrelated to religion. For instance, a smoking cessation group, which has no religious affiliation, teaches behavior modification without raising ethical issues.
The positive factors associated with religion seemingly cannot explain the results of studies of intercessory prayer, however, which Sloan particularly disputes. Recently, Sloan and his colleague, Emilia Bagiella, PhD, challenged the study of intercessory prayer, which suggested that prayer "may be an effective adjunct to standard medical care." Sloan and Bagiella asserted that "the lack of construct validity raises serious questions about this finding" and stated that the prayer and control groups had no difference in length of stay in the coronary care unit or in the hospital; did not differ on the Byrd Scale; and in fact only differed on the MAHI-CCU scale, which was constructed for the study's purpose.
Matthews believes that removing all of the health variables associated with religion may diminish study results but does not eliminate them. Good health behaviors of church attendees, in his view, are totally unrelated to the effects of intercessory prayer. Matthews believes that after confounding variables are removed, the remaining evidence cannot be explained only by science. In regard to Harris and coworkers' study on intercessory prayer, Matthews stated that no concrete medical evidence could explain why the persons for whom the prayers were offered had improved. In Matthews' opinion, that improvement could be attributed only to a supernatural force or to some unexplained type of energy.
Koenig asserts that it is "simply an epidemiological error" to deny the relation between religion and health because nonspiritual explanatory factors are involved. He believes that it is impossible to reduce religion to something that is devoid of such factors. "Religion is a package. It packages all of these potential health benefits: social support, improved coping, less depression, and a more optimistic outlook," he stated. He believes that research should stop focusing on determining whether religion is beneficial to health and instead focus on why it is. This viewpoint is supported by Strawbridge and colleagues, who conceded that they could not entirely account for their study results after factoring out health variables. The authors also recommended that additional studies be conducted to clarify the ways in which religion affects health.
Sloan believes that researchers need to take a step back. "It is entirely premature to consider religious activities as adjunctive medical treatments, given the very poor quality of the evidence purportedly linking religion to health outcomes and the substantial ethical issues raised," he stated. David Larson, MD, MSPH, chairman of the National Institute of Healthcare Research, believes that more studies should focus on the link between religion and health and try to determine what it is based on (physiologic factors, for example) and what creates it. More clinically relevant research is needed, "whether it's cardiovascular or gastrointestinal. Let's slow down on the prayer studies, and let's have better measures of religion and spirituality as well, spirituality outside of religion," he stated. Sloan fervently agrees that little clinically relevant research validates the link between religion and health. "Virtually all of the studies that have been conducted so far are methodologically deficient," Sloan asserted.


The Search for Explanations
Although some researchers agree that a link exists between religion and health, they continue to speculate about its origin. Matthews, like Koenig, believes that religion itself promotes good health behaviors and that religious doctrine incorporates many health-enhancing factors.
The Navajos believe that negative thoughts can lead to illness; perhaps the other side of the coin reflects the "faith factor," as Matthews called it. A strong faith in a greater power may improve health for various reasons. Koenig believes that being part of a religious community and having a strong belief system can benefit health in ways that cannot yet be measured. In addition, the effect of religion and intercessory prayer on health cannot be completely explained.
Koenig contends that religion encompasses both measurable and inexplicable components. "On scientific grounds there is good evidence, in my view, that religious commitment… is associated with better health. And then there's this tantalizing idea that there's something beyond the social support, beyond the lifestyle and the meditation. Scientifically, you would say that's something that we can't explain. A person of faith would say that's the hand of God."


Why Now?
No one is sure what has caused the recent increase in research examining the link between religion and medicine. Some studies seem to suggest that the trend evolved out of patient need. For example, in one survey (Arch Intern Med. 1999;159: 1803-6), 45% of 177 patients said that their religious beliefs would affect their decisions upon serious illness; of this 45%, 94% felt that physicians should ask patients about their religious beliefs. In 1996, USA Today Weekend and Time commissioned surveys to determine whether patients thought that religion should be combined with medicine. Two thirds of respondents wanted their physicians to address religion with them. Dana King, MD, of East Carolina University, Greenville, North Carolina, surveyed his patients and found that 48% of those who were hospitalized wanted their physicians to pray with them.
Why do patients feel that their physicians should address religion, or more precisely, why do they feel that way now? One reason could be the negative view of the health care system that has developed in recent years. Many patients believe that medical care is becoming increasingly depersonalized, primarily as a result of managed care. Patients may believe that the provider-patient relationship could become more personal if it included religious aspects. In addition, the two healing traditions of medicine and religion have become more segregated in this century than at any point in history. Patients who have realized that science cannot solve every problem or cure every ill may be yearning for a reincorporation of religion and medicine.
Sloan concedes that religion has its benefits but continues to dispute the role of religion in health.


Ethical Considerations
Beyond the question of the benefits of religion to health lies another ethical concern: Can religion be harmful to patients? Sloan points out that patients may be made to feel guilty or "insufficiently faithful." Matthews, Larson, Koenig, and many other physicians strongly advocate the blending of religion and medicine on some level. However, others believe that physicians should not become involved in areas outside of their expertise, and that doing so can be a misuse of valuable treatment time. It also has the potential for being downright unethical, as physicians may unduly influence a patient's beliefs. Sloan and Bagiella believe that "medicine should [not] take on religious practices as adjunctive treatments. To do so flies in the face of the vast majority of empirical evidence and raises serious ethical issues." Additionally, other factors beside religion have been identified as positively influencing health, such as marital and economic status. The question then becomes: Where should physicians draw the line? Sloan believes that physicians recommending religious activities to patients is akin to advising patients to marry or advising patients on their financial portfolio to improve health. Sloan asserts, "There's just no evidence that there's any impact apart from the conventional pathways that we already know about. It's a serious ethical intrusion."


Medicine's Response
Although Sloan and Bagiella raise valid concerns, the trend is clearly toward an intertwining of religion and health. Approximately 30 U.S. medical schools have incorporated some kind of religious or spiritual teaching into their curricula. Faculty at Harvard Medical School, Boston, Massachusetts, are teaching medical students how to obtain a spiritual history and how to discuss related concerns with their patients. Washington University School of Medicine in St. Louis, Missouri, offers courses in which medical students can explore their own and their patients' spirituality. Yale School of Nursing, in conjunction with the Divinity School and the Yale-New Haven Hospital, New Haven, Connecticut, is teaching both health and pastoral professionals ways in which to appropriately address spiritual and physical concerns.
Despite these changes in medical school curricula, King discovered that although many patients want their physicians to pray with them, less than 1% of physicians are actually doing so. The physician's role regarding religion is quickly becoming a subject of intense debate. Even when physicians agree that religion positively affects health, they are divided on what, if anything, they should be doing about it.
Koenig and Larson strongly urge physicians to address religion with their patients. Koenig believes that "doctors have been ignoring this because they felt it was unrelated or related in a negative way to health." At the same time, however, the subject needs to be addressed sensitively. Koenig suggests that physicians ask patients how important religious beliefs are to them but does not believe that physicians should "prescribe religion." Larson thinks that it is imperative to respond to patient need on this issue regardless of study results. "I'm not saying we should address it because the research says it's a factor that tends to be a healthy factor. We should address it because the patient surveys are saying that we should be addressing it," he remarked.
However, Brian Haynes, MD, professor of clinical epidemiology and medicine at McMaster University and editor of the American College of Physicians-American Society of Internal Medicine's ACP Journal Club, adamantly disagrees. "Dictating what the medical profession should and shouldn't do solely on the basis of patient need isn't reasonable," he stated. He believes that patient need should be considered, but he also feels that all interventions should be supported by some evidence of benefit.
Sloan believes that religion should have an extremely limited role in the physician's office. "In these days of managed care, when you have such limited amounts of time with patients, surely there are more important things to do in the interaction than pursuing some issue that has very poor empirical support and raises all of these ethical issues," he asserted. Koenig agrees that time is short but believes that addressing religious aspects with patients is crucial. "Now we're getting stuck in this position where we're seeing patients in 10 minutes. I can hardly address the medical and psychiatric issues, let alone the spiritual issues-but it doesn't take that long to affirm the patient's religious beliefs and how to cope," he commented.
Sloan does not believe that physicians should totally ignore the subject of religion. Rather, he thinks that patients who have spiritual concerns about their health should be encouraged to seek the help of trained professionals, such as health care chaplains. Sister Patricia Talone, PhD, vice president of mission services and ethicist at Unity Health in St. Louis, Missouri, agrees with Sloan on that point but adds, "We don't always have enough chaplains to care for patients' needs. Two of our hospitals are rural, and there isn't always a chaplain available."
Talone feels that physicians could be more involved in patients' religiosity but that the level of such involvement should be dictated by context. "I firmly believe that in many smaller communities where the doctor knows the family well or the doctor has had a long-standing relationship with the patient or family, it is not at all inappropriate for the physician to bring up the spiritual issue or even to take a moment to pray with the patient."
Koenig strongly believes that physicians will benefit from adding a little religion to their practices. "Religion is good medicine," he stated. "Most of us became doctors because we really wanted to help people. I think this can bring back what medicine needs, what it's lost, and what doctors really want. It will give their practices meaning."
Whatever their position on these issues, most people would agree that a physician's own beliefs are important. That is, physicians must be comfortable with the idea of introducing religion into the practice of medicine before they take any further steps. They should not feel pressured to do anything that conflicts with their deepest beliefs.

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