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Religion, Spirituality, and Medicine: How Are They Related and What Does It Mean?

2001; Elsevier BV; Volume: 76; Issue: 12 Linguagem: Inglês

10.4065/76.12.1189

1942-5546

Harold G. Koenig,

Religion, Society, and Development

A long historical tradition connects religion, medicine, and health care. Religious groups built the first hospitals in Western civilization during the fourth century for care of the sick unable to afford private medical care. For the next thousand years until the Reformation and to a lesser extent until the French Revolution, it was the religious establishment that built hospitals, provided medical training, and licensed physicians to practice medicine. By the end of the 17th century, however, the scientific profession of medicine had nearly completely separated away from its religious beginnings.1Koenig HG McCullough ME Larson DB Handbook of Religion and Health. Oxford University Press, Oxford, England2001Crossref Google Scholar Likewise, the profession of nursing emerged directly from religious orders that until the early 1900s staffed the majority of hospitals both in the United States and other Western countries. Over the past decade, the medical community has become increasingly interested in the possibility of bringing down the wall that has separated religion from medicine for more than 2 centuries. The discussions for and against this reconnection have intensified of late, and the debate is now raging both within the medical field and outside it.2Sloan RP Bagiella E VandeCreek L et al.Should physicians prescribe religious activities?.N Engl J Med. 2000; 342: 1913-1916Crossref PubMed Scopus (251) Google Scholar Research appearing in mainstream medical and public health journals reports a connection between religion and health.3Pargament KI Koenig HG Tarakeshwar N Hahn J Religious struggle as a predictor of mortality among medically ill elderly patients: a 2-year longitudinal study.Arch Intern Med. 2001; 161: 1881-1885Crossref PubMed Scopus (541) Google Scholar, 4Strawbridge WJ Cohen RD Shema SJ Kaplan GA Frequent attendance at religious services and mortality over 28 years.Am J Public Health. 1997; 87: 957-961Crossref PubMed Scopus (509) Google Scholar Even the National Institutes of Health has held several consensus conferences5NIH Consensus Conference. Methodological Approaches to the Study of Religion, Health, and Aging. National Institute of Aging and Fetzer Institute, March 16–17, 1995.Google Scholar, 6NIH Consensus Conference. Spirituality, Religion, and Health. Office of Behavioral and Social Services Research, National Institutes of Health, Fall 1999.Google Scholar on the topic and is now beginning to fund investigations, including randomized controlled trials,7Prayer in Black Women With Breast Cancer. A 5-year project (randomized controlled trial), funded by the National Center for Complementary and Alternative Medicine and awarded to the Johns Hopkins Center for Alternative and Complementary Medicine, August 2000.Google Scholar, 8Mechanisms and Therapeutic Effects of the Relaxation Process. A 3-year project (randomized controlled trial) to evaluate the effects of meditation on withdrawing hypertensive medications in elderly patients, funded by the Centers for Disease Control and Prevention and awarded to the Mind/Body Medical Institute, Harvard University, October 2000.Google Scholar to understand the effects of religion on health. Furthermore, all major US Department of Health and Human Services divisions this year have been given a presidential mandate to encourage research9Announced at the Center for Substance Abuse Treatment's Faith and Community Partners Initiative National Focus Group meeting, by Elizabeth Seale, director of the US Department of Health and Human Services Center for Faith-Based and Community Initiatives, July 26, 2001.Google Scholar on and remove the barriers from faith-based community organizations delivering mental health and substance abuse services. Many physicians question the appropriateness of addressing religious or spiritual issues within a medical setting, and almost all are uncertain on how to go about this. Opponents of integration argue that the research base connecting religion with better health is weak and inconsistent, depending primarily on epidemiological studies that demonstrate association, not on clinical trials that prove causation. They claim that religion is a personal and sensitive area of most patients' lives, too private for physicians to inquire about, regardless of whether it is connected with health. Worse still, they see any involvement by physicians in this area as potentially coercive-physicians imposing their own religious beliefs on vulnerable patients dependent on them for care. Furthermore, if physicians imply that religious involvement helps people stay healthy, then people who become sick may feel guilty for not having enough faith, thus adding to the burden of suffering. An important minority of patients (at least one third) do not want physicians delving into spiritual issues with them.10King DE Bushwick B Beliefs and attitudes of hospital inpatients about faith healing and prayer.J Fam Pract. 1994; 39: 349-352PubMed Google Scholar Finally, addressing spiritual issues takes physicians outside their area of expertise, and most do not have either the training or the time to explore this area with patients. All of these are valid and important concerns. In this issue of the Proceedings are reported 2 different approaches to studying the relationship between religion and health. One is a review by Mueller and colleagues11Mueller PS Plevak DJ Rummans TA Religious involvement, spirituality, and medicine: implications for clinical practice.Mayo Clin Proc. 2001; 76: 1225-1235Abstract Full Text Full Text PDF PubMed Scopus (366) Google Scholar of research exploring the effects of religion on mental and physical health. In that review, religious beliefs and practices are thought to evoke health effects through psychosocial, behavioral, and physiological mechanisms that are known, understood, and accepted within the field of traditional science. The strength of this review is its comprehensive nature and its focus only on research studies that had findings explainable through scientifically rational pathways. The weakness of this approach is that most of the studies reviewed were either cross-sectional or prospective cohort studies that observed relationships as they occurred and evolved naturally over time. Such studies cannot prove causation, although the fact that there are so many of them, conducted in many different populations, at different times, by different investigators, using different methods does provide considerable circumstantial evidence that supports causation. To be fair, the authors also review a number of clinical trials, particularly those involving meditation, that appear to support the findings of the much more numerous epidemiological studies. The other approach described in this issue of the Proceedings by Aviles and colleagues12Aviles JM Whelan E Hernke DA et al.Intercessory prayer and cardiovascular disease progression in a coronary care unit population: a randomized controlled trial.Mayo Clin Proc. 2001; 76: 1192-1198Abstract Full Text Full Text PDF PubMed Scopus (106) Google Scholar is a double-blind, randomized controlled trial that examined the effects of intercessory prayer on health outcomes. Patients were randomized to either a group being prayed for or to a control group; neither physicians nor patients knew who was being prayed for, nor did the intercessors know the patients they were praying for. This is one of about a dozen studies of intercessory prayer now reported in the medical literature.1Koenig HG McCullough ME Larson DB Handbook of Religion and Health. Oxford University Press, Oxford, England2001Crossref Google Scholar The strength of this study is the method used-it is a clinical trial capable of proving causation. It is well designed and soundly executed, addressing many of the methodological flaws of previous intercessory prayer studies. The weakness of the study is that the effect explored has no basis within the current scientific paradigm. If found to be true, such an effect would indeed challenge our understanding of the universe and perhaps even overturn much scientific knowledge accumulated to date. Not only are there scientific difficulties with such a finding, there are also theological ones.13Myers DG Is prayer clinically effective?.Reform Rev. 2000; 53: 95-102Google Scholar Thus, not only would most scientists expect a null result from such a study, but most Western theologians would as well. Furthermore, this study contributes almost no information to the area of research reviewed by Mueller and colleagues (who have not included a single intercessory prayer study among the 146 references cited in their article). Despite the vast amount of research on the religion and health relationship that has already accumulated (more than 1200 studies at last count),1Koenig HG McCullough ME Larson DB Handbook of Religion and Health. Oxford University Press, Oxford, England2001Crossref Google Scholar much remains unknown. Clinical trials based on a scientific framework are greatly needed to examine the effects of spiritual interventions on health outcomes. Clinical trials are also needed to assess the effects of spiritual interventions by physicians in medical settings on the patient-physician relationship, compliance with treatment, use of health services, disease outcomes, and quality of life. Clinical trials, however, also have limitations in terms of generalizability, and therefore prospective cohort studies of large populations are still needed. Good science looking at the potential negative effects of religion on health is lacking. As Mueller and colleagues point out, systematic studies that find mainstream religious activity linked with negative health have been rare, and methodological weaknesses of even those few studies interfere with interpretation.1Koenig HG McCullough ME Larson DB Handbook of Religion and Health. Oxford University Press, Oxford, England2001Crossref Google Scholar A recent report found that hospitalized patients with religious struggles that created stress (feeling punished or deserted by God, feeling abandoned by their religious community, questioning God's love and power) experienced significantly worse mental health and greater mortality during the 2 years following hospital discharge.3Pargament KI Koenig HG Tarakeshwar N Hahn J Religious struggle as a predictor of mortality among medically ill elderly patients: a 2-year longitudinal study.Arch Intern Med. 2001; 161: 1881-1885Crossref PubMed Scopus (541) Google Scholar Religious or existential turmoil, then, may impair recovery-underscoring the importance of physicians' identifying such patients and making appropriate referrals. Without appropriate knowledge, addressing spiritual issues in clinical practice can be a risky undertaking. Some of the dangers and pitfalls have already been mentioned, and some may be hard to predict, given the lack of data. However, physicians are beginning to appreciate that the majority of their patients are religious and use religious beliefs to cope with sickness, that existential issues and spiritual struggles are common among patients, that religious beliefs influence the medical decisions that patients make, and, for all these reasons, that religion might ultimately affect both psychological health and medical outcomes. Patients who have an optimistic belief system that gives life meaning and purpose in the setting of pain and suffering, those who have a large group of supportive friends committed to their welfare, and those who live healthier lifestyles and abuse their bodies less often with drugs, alcohol, and cigarettes, are bound to be healthier and recover more quickly from illness. Who could deny that such factors are relevant to the practice of medicine? How, then, might a sensible clinician proceed? Despite the many unknowns and the need for further research and greater understanding of these relationships, physicians can even now begin to address the spiritual needs of patients and yet avoid most of the dangers and pitfalls.14Koenig HG. Spirituality in Patient Care. Radnor, Pa: Templeton Foundation Press. In press.Google Scholar The following recommendations are based on clinical experience and common sense, not systematic research. As Mueller and colleagues suggested, physicians can take a spiritual history-find out whether religious or spiritual beliefs are used to cope, are evoking religious struggles, are likely to influence medical decisions, or are responsible for other special needs that trained clergy may help with. A spiritual history should be taken in a way that does not endorse religion as either desirable or undesirable, but rather sends the message that religion and spirituality are an important area that may influence health for better or worse. Spiritual assessment need not be done at every visit, but rather on occasions when there is more time, such as during a new patient evaluation or on hospital admission. It should not replace a comprehensive and competent evaluation of medical problems. As Mueller and colleagues point out, the research is not good enough (and may never be good enough) to justify physicians' prescribing religion to nonreligious patients. If the patient is not religious or does not want physician involvement in this area, then questioning should quickly move away from religion and toward what helps the patient cope and gives life meaning. In the majority of cases, the physician should not attempt to address complex spiritual needs of patients. However, when the patient is reluctant to talk with clergy and prefers to discuss spiritual matters with a trusted physician, taking a little extra time to listen and be supportive is usually all that is required. Providing support for religious beliefs and practices that do not conflict with medical care is appropriate. When beliefs conflict with medical care, however, it is important not to criticize the belief, but rather to listen, gather information, enter into the patient's world view, and maintain open lines of communication, perhaps enlisting the help of the patient's clergy.14Koenig HG. Spirituality in Patient Care. Radnor, Pa: Templeton Foundation Press. In press.Google Scholar Religious beliefs may have a powerful influence on the health of our patients, and we need to know about them. Intercessory Prayer and Cardiovascular Disease Progression in a Coronary Care Unit Population: A Randomized Controlled TrialMayo Clinic ProceedingsVol. 76Issue 12PreviewTo determine the effect of intercessory prayer, a widely practiced complementary therapy, on cardiovascular disease progression after hospital discharge. Full-Text PDF Religious Involvement, Spirituality, and Medicine: Implications for Clinical PracticeMayo Clinic ProceedingsVol. 76Issue 12PreviewSurveys suggest that most patients have a spiritual life and regard their spiritual health and physical health as equally important. Furthermore, people may have greater spiritual needs during illness. We reviewed published studies, meta-analyses, systematic reviews, and subject reviews that examined the association between religious involvement and spirituality and physical health, mental health, health-related quality of life, and other health outcomes. We also reviewed articles that provided suggestions on how clinicians might assess and support the spiritual needs of patients. Full-Text PDF