Should physicians wade into the spiritual area during medical treatment?

doctorreligion.jpg Credit: Andrei Tchernov

Imagine you’re in an examination room for your annual physical. While taking your medical history, your physician notes that heart disease runs in your family, and then asks if you’re religious.

“I was raised Catholic but haven’t gone to church in years,” you say. Surprisingly, your doctor suggests that you start attending Mass again, as studies have shown religion protects against cardiovascular disease.

An unlikely scenario, yes, but the notion that the wall separating medicine and religion ought to be torn down has gained popularity over the last two decades. 

Hundreds of studies examining the link between religion or spirituality and health have concluded that religious activity promotes wellbeing, from protection against cancer to schizophrenia and hypertension. Some members of the medical community are taking the association seriously, probing into a patient’s spiritual history to prescribe treatment or advocating prayer with patients. In fact, more than half of the medical schools in the US now offer courses on religion, spirituality and health.

Overall, data tends to support a positive relationship between religion and health, say the authors of the Handbook of Religion and Health—a review of 1,200 studies. Such evidence, reported in scientific journals and the media, is getting both doctors’ and patients’ attention and should be applied in medicine, according to Harold G. Koenig, one of the book’s authors and co-director of the Center for Spirituality, Theology and Health at the Duke University Medical Center.

“If you ask people what enables them to cope, what helps them get through difficult times, many tell you it’s their religious beliefs,” he said. “When you measure religious beliefs, you find that they’re related to better mental health, better coping and greater life satisfaction.”

However, some researchers remain unconvinced, questioning whether religion should enter into the doctor-patient interaction at all, despite the abundance of studies. These critics insist there is a paucity of evidence proving the association.

“The methodology in most of these studies is very weak,” said Richard P. Sloan, professor of behavioral medicine at Columbia University. He, along with his colleagues, began publishing reviews of such studies in 1999, highlighting methodological flaws, conflicting findings and ambiguous data.

“The strongest evidence is in the studies that show association between attendance at religious services and mortality,” he said.

People attend church for reasons that have little to do with faith such as tradition, to meet people socially or to make business contacts, said Sloan, who is also the author of the forthcoming Blind Faith: the Unholy Alliance of Religion and Health. Furthermore, he added, studies indicate that people often inflate their church attendance when surveyed.

“Attendance at religious services is an exceptionally crude index,” Sloan said. “We don’t have any idea what the true degree of religious service attendance is, and we have no idea how that self-presentation bias is altering the findings.”

Lynda H. Powell, a cardiovascular epidemiologist and professor of preventative medicine, agrees with Sloan that religious attendance is the flaw in the argument for a causal link. Powell was lead author of a 2003 National Institutes of Health review on religion/spirituality and mortality, morbidity, disability or recovery from illness.

The authors found that data failed to support both the hypothesis that deeply religious people are physically healthier and that spiritual activity slows the progression of cancer and improves recovery from acute illness. They also observed a 25% reduction in risk of mortality in healthy religious service attendees after controlling for confounders.

“We understand that there’s an effect but we don’t understand why the effect exists,” said Powell, who was surprised by the robustness of this discovery, and called the results an “epidemiological puzzle.”

Powell’s latest research, which she is currently preparing for publication, may be a step toward solving the puzzle. Looking at daily practices of people across nine religious backgrounds, she found participants tended to do “quieting activities”—such as praying, chanting or meditating—regularly throughout the day. She also noticed that participants waited before responding to a stressor or enlisted others to deal with difficulties—techniques often taught in stress-reduction programs.

“Becoming mature spiritually is akin to being very effective at coping with stress,” said Powell.

If religious involvement leads to better coping skills, it could lower stress levels and decrease mortality. Nonetheless, it’s unknown whether a physician promoting religious practices would have the same effect. After all, patients rarely follow physicians’ recommendations to make behavior changes, Columbia’s Sloan said.

Furthermore, there are ethical considerations: Doctors promoting a non-medical agenda could violate implicit norms of the doctor/patient relationship, intrude on patients’ privacy or cause harm if a patient’s health or treatment fails, leading he or she to believe God did not care.

While doctors encouraging patients’ religious practices might seem innocuous, physicians could face the inappropriate task of determining which practices are acceptable or unacceptable. For instance, supporting a Jewish patient’s keeping Sabbath or a Muslim patient’s daily prayer is quite different from encouraging a patient to participate in Appalachian snake-handling ceremonies.

For now, it’s up to each physician to decide how (or if) to address religion. Over the past five years, guidelines for conducting spiritual assessments have become available on the websites of the American Medical Association and the American Academy of Family Physicians. One article posted to the AMA website offers a variety of suggestions to the physician for the patient’s spiritual care. These include doing nothing more religiously, incorporating the patient’s own spiritual resources into preventative/adjuvant care, modifying medical treatment or referring the patient to a trained clinical chaplain. A disclaimer at the end of the article noted that it does not necessarily reflect the views and policies of the AMA.

Meanwhile, medical schools train doctors to take a detailed spiritual history without imposing their own beliefs on patients, said Duke’s Koenig.

“Doctors are coming out a lot more well-rounded and able to address these issues, and can realize the power that religious faith can have in terms of healing and sometimes in terms of disease, also.”

Physicians shouldn’t proselytize to patients, but connect them with a spiritual care expert if they have any spiritual needs, he added. 

Sloan disagrees warns of putting too much emphasis on religion. Physicians should only conduct simple queries about what patients value, he said, which may or may not include religion.

“Why not conduct a dedicated financial history,” he said, “or a dedicated sports history or a detailed pornography history?”

By probing too far into a patient’s life, Sloan said, “physicians may do more harm than good.”

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Originally published March 22, 2006

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