BUTLER: What does the evidence show in terms of the
connection between religious practice and other characteristics of
our society: poverty, welfare, health? Also, what might be the
implications of this research and analysis, if any, for public
policy? These are the objectives of this Center, and we are very
pleased it pulls together a lot of the work that we have been doing
in various parts of the Foundation for some years and gives it a
event today is to explore the relationship--again, I say if
any--between religious practice and personal health and recovery
from illness. Hence the provocative title: "Is Prayer Good for Your
people have fairly strong views about this one way or the other,
and generally speaking, most people at some point in their lives or
in their religious practice do at least call for some assistance
for their recovery or the recovery of their friends. In our
synagogue, we say the misheberach, which calls for physicians to be
as skillful as they possibly can be in dealing with people who are
ill, and calls for those who are ill to have the strength to deal
with their illness.
kind of calling for assistance from God is a very common feature of
all religions, and for all of us, even if we're only mildly
religious, generally speaking, there is a point in our lives where
we call in that way. Also, there's a lot of anecdotal evidence in
the medical profession and elsewhere about remarkable occurrences
that people have seen in their medical practice or in their
what is not as generally understood is that there is considerable
scientific research analyzing the potential connection between
religious practice and prayer and health. This research has been
undertaken at some of our most prestigious universities around the
country and is the basis of dozens, if not hundreds, of major
scientific articles examining this connection. This connection has
also been the subject of a number of major media pieces and
articles, including a piece on National Public Radio, which
featured at least two of our speakers this morning, and an article
in; Parade magazine, which you may have seen.
we intend to do today is to give you an overview of this research
and to ponder the validity of this research. One of our speakers in
particular has been very critical of the methodology and assumed
implications of this research. It's a very balanced approach to
help us, as we are trying to do in our Center, to investigate, to
examine what the research actually says, and to ponder its
have a panel of some of the most distinguished scholars in this
field from around the country here with us this morning. In fact,
two of them have debated each other from time to time on the radio;
this is the first time they've actually met fact-to-face to discuss
first speaker is Dr. Harold G. Koenig, who is on the faculty at
Duke University as a tenured associate professor of psychiatry and
an associate professor of medicine. He is director and founder of
the Center for the Study of Religion/Spirituality and Health at
Duke University. He is the author of dozens of books and articles
and chapters of books.
research on religion, health, and ethical issues in medicine has
been featured in over 35 national and international TV news
programs, including all the major U.S. networks. He has presented
his research before the United Nations. His latest books include
The Healing Power of Faith: Science Explores Medicine's Last Great
Stuart M. Butler, Ph.D., is Vice
President for Domestic and Economic Policy Studies at The Heritage
KOENIG: Care of the sick originated from religious
teachings. The first hospitals were built and staffed by religious
orders. Many hospitals even today are religiously affiliated. The
first nurses and many early physicians were from religious
until the mid-20th century did a true separation develop. This was
partly a result of the teachings of Freud. Since the mid-20th
century, however, religion is seen in medicine as irrelevant,
neurotic, or bothersome and conflicting with care.
Spiritual needs of patients are ignored or
ridiculed. The relationship is improving but remains controversial.
There are difficult questions that remain, and there are clearly no
you look at the population of the U.S., the latest Gallup polls,
belief in God, membership importance, and attendance, this is done
by age; you can see the different categories. When you look at
belief in God, it's straight across: about 95 percent of the
Membership changes, but among the over-65
population, between 75 and 80 percent are church members. With
regard to the importance of religion, among the over-65 age group,
about 75 percent indicate that religion is very important to them.
Of course, as people become sick and ill and go into the hospital,
it becomes even more important to them. It's amazing to me that in
the over-65 population, we are looking at rates of 55 to 60 percent
who are attending church weekly or more often.
people, especially those over 65, are religious and turn to
religion for comfort, support, and hope when they become sick. The
medical profession has largely ignored this.
regard to mental health, prior to the year 2000, there are a number
of studies looking at well-being, hope and optimism, purpose and
meaning in life in the 20th century, and these are the studies that
show a positive relationship between religion and these various
things. (See Chart 1) You can see depression, anxiety and fear,
marital satisfaction, social support: 19 of 20 studies on substance
abuse. The strongest effects are found in stressed populations.
It's important to remember that.
Since the year 2000, there's been a large, growing interest in this
area. Entire issues of various secular journals have been devoted
to this topic as well as a growing amount of research and
discussions. Between 1980 and 1982, there were 101 articles in the
Psyc Lit data base; by 2000 to 2002, there were over 1,100
articles. It had gone up by almost tenfold. These are not all
research studies, but they involve discussions and at least are a
reflection of the interest in the area. (See Chart 2)
There are reasons why religion can
influence coping. These are logical, rational: It provides a
positive, optimistic world view; provides meaning and purpose to
life; helps people to psychologically integrate negative things;
gives people hope; enhances their motivation; personally empowers
them and gives them a sense of control.
praying to God, they feel they can influence their outcome, so they
are not as helpless. Religion also provides role models for
suffering--Job, for example--as well as guidance for
decision-making, which helps to reduce stress; answers to ultimate
questions that science cannot answer; and social support, both
human and divine. Most important, it is not lost with physical
illness or disability.
Better mental health in turn is related to
better physical health. In the last six months, there have been
major studies in JAMA, Proceedings of the National Academy of
Sciences, and the Lancet showing the connections between better
mental health and better physical health--depression in particular,
affecting health-related quality of life in coronary artery disease
(CAD), affecting Interleukin-6 levels (an indicator of immune
functioning) two to three years after the death of the patient.
Depressed patients have nearly double the mortality in CAD, and
there is experimental evidence that negative affect (or negative
mood) influences immune function. (See Chart 3)
Therefore, we have a logical reason why religion might influence
physical health through mental health, through enhancing social
support, through influencing health behaviors, all affecting
physical health outcomes.
let's look at how religion is related to physical health and
medical outcomes. There are many studies out there: different
populations, different samples, different investigators, different
time periods, and different disorders. Many of these studies have
methodological weaknesses, but not all of them. Almost all are
epidemiological; there are very few clinical trials, except for in
meditation. (See Chart 4)
This gives you a sense of the research that is out there. In three
of three studies you find a connection between religious
involvement and immune and endocrine function; in five of seven
studies, the religious experience lower mortality from cancer; in
14 of 23, they have significantly lower blood pressure; in 11 of
14, they have lower mortality; and in 12 of 13, clergy mortality is
lower. In addition, numerous new studies are now in review that are
currently being evaluated by journals.
Let's look at the strength of this effect.
(See Chart 5) Odds ratios are hard to understand, but binomial
effect size helps to explain the magnitude of the impact in lay
terms. When 50 percent of a population has died, the number of
additional people alive per 100, or the number of people dead per
100, because of the activity equals the binomial effect size. The
binomial effect size can be determined from odds ratios.
Here's an example. Exercise rehab following coronary artery
disease--these effects are all the results of meta-analyses. The
odds ratio is 1.35, which means a 35% greater chance of being alive
in coronary artery disease patients who undergo exercise rehab.
This also means 3.7 people are alive per hundred as a result of
that behavior when 50 percent of the mixed population has died.
considering that there are almost 13 million people with CAD, you
divide that by 100, and multiply that times the binomial effect
size of 3.7, and this results in almost 500,000 people with CAD who
are alive because of exercise rehab. For psychosocial treatments
following CAD, the binomial effect size is 6.6 people per hundred,
with slightly more than 850,000 people with CAD alive as a result
of psychosocial treatments in CAD.
cholesterol-lowering drugs and CAD, again affecting almost 13
million, with an odds ratio of 1.35, this means that almost 500,000
people with CAD are alive because of drugs like Lipitor. For
hazardous alcohol use, 1.24 is the odds ratio, translating into 2.6
extra deaths per hundred, resulting in--given the high prevalence
of hazardous alcohol use--about 750,000 fewer people alive.
Let's look now at weekly religious
attendance. Here is a single religious variable, looking at a
single outcome, mortality. The McCullough meta-analysis published
in 2000 has the best odds ratio for the effect of religious
attendance on mortality. It was 1.37, meaning a binomial effect
size of 3.9. Given that there are 122,650,000 people attending
religious services weekly or more often in the United States, this
results in 4,783,380 fewer deaths as a result of religious
attendance (if this relationship is causal).
NIH Consensus Conference, whose results were published in 2003,
with confounders only in the model (the best estimate of the true
effect), resulted in an odds ratio of 1.43, which translates into a
binominal effect size of 4.5, with even a greater potential number
of people affected (5,519,284). Confounders mean age, sex, race,
health status. The odds ratio for the full model (i.e., with
explanatory variables such as social support, health behaviors,
mental health, etc. in the model) is 1.33, with 4,415,428 more
people alive. This means that even when you control for factors by
which we think religion exerts its effects on health (social
support, etc.), you still end up with an impact involving nearly
4.5 million people that cannot be explained.
last four largest studies that controlled for all these variables
got an average odds ratio of 1.37, again agreeing with the
The Strawbridge study, looking at women,
found in the full model this odds ratio (1.52), resulting in a
binomial effect size of 5.2 per 100. Given that 69 million women
attend religious services weekly, this means that over 3,582,000
additional women might possibly be alive as a result of weekly
attendance. Compare this to the number of lives (2,252,900) that
cigarette smoking takes among women who smoke.
comparison to the number of lives potentially impacted by religious
attendance (i.e., 5,519,284), the population of Washington, D.C.,
is 572,000, and the circulation of Newsweek magazine is almost 3.2
the effect that religion has on health causal? There is limited
evidence from clinical trials that it is. Religious interventions
in religious patients with depression, anxiety, bereavement, and
pain caused depressive symptoms, anxiety, and bereavement to become
better more quickly. This is not only Christian interventions, but
also Buddhist as well as Islamic interventions.
are also clinical trials looking at meditation's effects on
lowering blood pressure, reducing cortisol, cholesterol levels, and
cardiac arrhythmias. These studies are not always perfect in terms
of the methodology. I'm sure we'll find out later more about their
weaknesses. But just because a study is weak doesn't mean it
doesn't provide any useful information. In all, the information we
have from clinical trials provides some evidence to support the
huge amount of evidence from epidemiological research that this
relationship may be causal. Epidemiological research by itself,
however, can also contribute to causality.
epidemiology, Hill's criteria for causation provide guidelines on
determining whether a relationship is causal. What is the strength
of the association? For religion and health, the strength is
moderate. What is the consistency of the relationship? The
relationship between religion and health is moderately consistent.
What about specificity? Religious attendance particularly affects
cardiovascular disease and stress-related diseases, as you would
expect, and therefore is specific.
about the temporality? In prospective studies, it appears that
religious attendance predicts mortality in the future, providing
evidence for temporality. What about a biological gradient? In both
the Hummer study and the Musick study, as frequency of church
attendance increased, the effect size on mortality also increased,
providing evidence for a biological gradient.
about plausibility? It is strong--highly plausible that religion
influences physical health. We have a model of how religion might
do this, acting through mental health, social support, and health
behaviors. What about coherence? Yes, it is also coherent. The
effects of religion are strongest in stress-related illness.
about experiment? This is the only one of the Hill criteria in
which the evidence is limited at present, given the relatively few
clinical trials that have been done in this area. What about
analogy? Yes, other psychosocial constructs, such as depression and
stress, influence disease course, as we saw earlier.
should physicians do about this? We can no longer justify that
religion is usually irrelevant to health, neurotic, or
health-damaging. But, while this is not sufficient to justify a
physician's prescribing religious advice or recommendations, there
are other reasons to justify limited physician involvement.
Religious beliefs impact medical
decisions. (See Chart 6) This is an important reason for clinicians
to address religious issues as part of routine clinical care.
Studies show that 66 percent of medical patients indicate that
religious beliefs would influence their medical decisions should
they become seriously ill. Here, in making a decision about whether
patients with end-stage lung cancer should receive chemotherapy,
family and patients ranked "faith in God" as second in importance,
even ahead of whether or not the chemotherapy would effectively
treat the cancer. When 300 oncologists were asked this question,
they ranked "faith in God" dead last among seven or eight other
important influential factors.
So there's a difference here between what patients are saying
affects their decisions on whether or not to receive chemotherapy
and what physicians think affects patients' decisions in this
regard. Physicians underestimated the importance of religion in
influencing patients' medical decisions with regard to
End-of-life decisions relate to religious
beliefs and can cause serious conflict. You see here a study
conducted in North Carolina, a random sample of women over age 40.
If they discovered a breast lump, what would they do? Forty-four
percent would trust more in God to cure their cancer than medical
treatment, and 13 percent believed that only a religious miracle
could cure cancer, not medical treatment.
religious beliefs having such a profound influence on medical
decisions, how can doctors practice good medicine without
communicating about these issues with their patients?
what do I recommend? Take a spiritual history. Because religion
influences coping with illness and medical decision-making, doctors
ought to take a spiritual history; respect, value, and support the
beliefs and practices of the patient; and orchestrate the meeting
of spiritual needs. Praying with patients is more controversial,
although in certain circumstances, I feel it is appropriate.
taking a spiritual history, what do you ask? First of all, you need
to introduce the subject to the patient. Why is the doctor asking
these questions? This needs to be explained so the patient won't be
surprised or wonder why the doctor is asking questions about
religion. The kind of information you want is as follows: Do
religious beliefs or practices provide comfort, or do they cause
stress? Don't imply that religion is either good or bad, only that
it can provide comfort or can cause stress.
might beliefs influence medical decision-making? Doctors need to
know that. Are there beliefs that might interfere with or conflict
with medical care? Is a person a member of a religious or spiritual
community, and is it supportive? Are there any other spiritual
needs that someone ought to address?
recommended: Do not prescribe religion to non-religious patients;
force a spiritual history if the patient is not religious; coerce
patients in any way to believe or practice; spiritually counsel
patients; engage in any activity that is not patient-centered; or
argue with patients over religious matters, even when they conflict
with medical care or treatment. Even so, many complex situations
summary, a religion-medical connection is not new or unnatural.
Many patients are religious and use it to cope with illness.
Religion is related to mental health, social support, and health
behaviors. Better mental health, in turn, and better social support
are related to better physical health.
Thus, religion should be related to
physical health. And when you examine it, it is. The relationship
is only moderate in strength, but it has a huge impact given the
number of people who are religious. There is growing evidence that
the relationship may be causal. Religion affects coping with
illness and medical decisions. Thus, physicians should communicate
with patients about these issues, but there are important
boundaries and limitations.
BUTLER: Thank you, Dr. Koenig, for a fascinating overview
of the issue and of the research evidence. We now have three other
speakers that will continue to look at this evidence and comment on
first is Dr. Christina Puchalski, Associate Professor of Medicine
and Health Care Sciences at the George Washington University
Medical Center here in the District of Columbia. She is also
founder and director of the George Washington Institute for
Spirituality and Health and one of the first in the country to
receive the John Templeton Award for Spirituality in Medicine,
which is a very distinguished award.
Puchalski has pioneered the development of medical school courses
in spirituality and health on a national level in an award program
she directs for the John Templeton Foundation. Her work has been
featured, like Dr. Koenig's, on a number of major television and
other programs, including "Good Morning, America," "ABC World News
Tonight," "NBC News," and the weekly series "Religion and Ethics
News Weekly" on PBS.
PUCHALSKI: What I would like to address in my comments has
to do with work that I do in educating physicians on the role of
spirituality and health. It's not just focused on religion. We
really talk about spirituality much more broadly defined.
have made many changes in medical education, and one of them is
that we teach courses on spirituality and health. In 1992, there
were three schools with courses, one of them being here at the
George Washington University School of Medicine. Now well over 65
percent of the medical schools have courses or topics related to
spirituality and health.
draw that distinction because in medical education, many of our
ethics and psychosocial courses are integrated into a larger
curriculum, often entitled "doctor, patient, and society." Ethics,
social issues, and spirituality are not specific courses but are
integrated into other areas of the curriculum.
Clearly, there's been a huge interest in
this. I'd like to talk briefly about why that is. One reason has to
do with the general movement in medicine, probably in the last 15
to 20 years, to recognize more than just the physical aspects of
think that's in response to the rise in technology in the last half
century, from the 1940s on, where there has been a change from an
art and science focus to more of a solely scientific focus and what
many of us in medical education call a disease model of education.
This is the model that physicians were educated on--and I was
trained in that model--to focus not so much on the person, but on
the disease. The next step after that is to be able to diagnose,
treat, and hopefully cure that disease.
much of the impetus in education and the way that our physicians
were trained, myself included, is to want to cure and fix the
problem. The public has responded negatively to that, with comments
in the public press and elsewhere that doctors are
"overtechnologicalized," so to speak: that they focus too much on
the disease and not enough on the person.
read in an article in the early 1990s that people were going to
complementary and alternative practitioners and paying large
amounts of money to see those practitioners, and yet would complain
about the $10 co-pay to see those of us that are M.D. physicians.
There have been numerous writings and some surveys--not scientific
surveys--indicating that the lay public wanted physicians, healers
that would listen to their other concerns and relate to their
spiritual concerns, not just their physical.
of the data came to the attention of the Association of American
Medical Colleges, who then embarked on a project called the Medical
School Objectives Project. This was a project that was started in
direct response to the public outcry about the training of
physicians and the fact that physicians were becoming too cold, too
technical, and that people wanted warmer, closer relationships with
the first Medical School Objectives Report, called Report One--and
these are available on the Association of American Medical Colleges
Web site, www.aamc.org--a group of medical educators achieved
consensus on four attributes that they felt were critical in
training physicians so that by the time the medical students
graduated at the end of four years, the faculty could be confident
that these students would exhibit these four attributes.
third and fourth attributes had to do with being skillful and
knowledgeable. Those get at the technical aspect, and clearly, we
have to be very good at that.
the first and second had to do with being altruistic and dutiful.
So this group of educators that was interdisciplinary felt a very
important aspect of medicine was our behavior with our patients.
What they stated is that we need to be compassionate with all of
our patients, and we need to understand our patients and their
illness and their health in the context of their stories: who they
are, their beliefs, their culture, their family, and their
as I was developing models of addressing spirituality in medical
education, that dovetailed with the AAMC's objectives to try to
create courses within the curriculum that would support this
second has to do with professionalism. There are many courses in
the last 10 years that have developed in medical school having to
do with professionalism: again, a concern on the part of medical
educators that we were training physicians who were not in touch
with their professional obligation to their patients. While those
courses are very detailed, many of them include ethical behavior of
physicians with their patients.
There's also a sense that we need to
impart to our future generation of physicians a sense of pride and
a sense of calling to that profession. What draws you to be a
physician? Why are you here, and how can that be nurtured
throughout your professional career? I use the word "calling." It
is a buzzword, but many medical students, religious or not, use
that sense of "I feel called to serve others." So, again, the
aspects of professionalism are again bringing back to medicine the
service aspect of our profession. We're not just here to fix and
treat a problem, but we're here to serve people.
While many illnesses are curable, in the
end, everybody will die. In the end, everybody will be facing
chronic illness. There are statistics that the top three causes of
death now versus 100 years ago are cancer, stroke, and heart
disease. In all those three illnesses, people are living much
longer with chronic illness.
hundred years ago, people would die from those three causes. Now,
because of treatments, people are living longer. But those are not
curable illnesses, so they are dealing with chronic illness and the
challenges that arise with chronic lifelong illnesses. How can we
as physicians serve our patients in that context?
Before the 1960s, medicine was practiced
largely in a paternalistic model; that is, physicians would dictate
to patients what to do, and there was very little collaboration
with patients about their preferences and their wishes. Largely,
through the 1960s and '70s, that has changed and in a way has swung
to the other side. I think we've gone a little bit too far and that
now many physicians just abdicate responsibility completely and
say, "What would you like to do, and we'll do that."
think we're recognizing that we need to find a happy middle ground.
Our courses try to address that. I think the happy middle ground is
a partnership with our patients where we still act as experts in
the area that we're experts in--and that's the medical side, the
recommendations for treatment--but we act as partners and as equals
when it comes to helping patients cope with their illness or
helping patients find some decision that's good for them.
terms of patient care, I think that Dr. Koenig addressed many of
the research findings. Interestingly, our medical school courses
are not so much based in the research as they are in ethical
principles. But some of the research data do impact our courses,
and that has to do with coping.
is it that our patients come to cope with their illness? Illness, a
loss, can cause people to question who they are at their very core,
their meaning and purpose in life. People will argue, "Well, I can
understand that your patients might deal with that. But why not
just have the chaplain deal with it? Why not just have the clergy
person deal with it?"
Because, oftentimes, those questions arise
in the patient's lives for the very first time in the doctor's
office. I'm an internist. I see patients. I have an active clinical
practice. So I can tell you from my patient experiences that it is
in those offices, when I tell someone that they have a diagnosis of
cancer or diabetes or heart disease, or that their significant
other is dying, it is in those conversations that these questions
come up, and not so much outside of the clinical setting.
physician may be the very first person to deal with some of these
issues. That's the overriding principle. But there are also ethical
issues, and Dr. Koenig alluded to some of them. Religious,
spiritual, and cultural beliefs can impact how people understand
Very, very common in a religious
population is to question the illness and wonder if perhaps people
are being punished: punishment from God. I sinned, and therefore I
have this illness. That can impact how a person is going to react,
how open they are going to be to treatment, to treatment options,
to coming back to visit the physician.
important that I, as a physician, know that that may be a dynamic
operating in how a person understands their illness so I know how
to communicate my recommendations and how to work with my patient.
Maybe the appropriate thing to do before recommending any therapy
is to suggest that that person talk further with their clergy
person about those issues. Or perhaps I recognize some guilt and
some other issues that have been unresolved; maybe pastoral
counseling, maybe even counseling with a psychiatrist might be
There's also been some data from Ken
Pargament on negative and positive religious coping that plays a
lot into this first ethical parameter. Religious beliefs, spiritual
beliefs can affect decision-making. Dr. Koenig referred to a couple
of studies, but particularly around end-of-life care, religious
beliefs play a large role. Whether someone would like to be taken
off the ventilator or not, whether people are comfortable using
feeding tubes--religious beliefs really affect those decisions.
Sometimes patients will have these
religious beliefs, but they may come from an unclear understanding
of what their religious principles hold. So it's very important to
work in partnership with spiritual care providers who are trained,
such as chaplains, who can help people understand their decisions.
When it comes to decision-making, I hope that as a physician, I
provide medical informed consent. Chaplains provide spiritual
informed consent, which is not something people fully realize.
chaplains who are trained may challenge patients about their belief
system so that, in the end, when the patient arrives at a decision
for a particular course of action with treatment or end of life,
they are comfortable and sit comfortably in that decision,
understanding the medical consequences as well as their religious
and spiritual beliefs. It also could, for many patients, be a
of these data are survey data. Is it strong research, scientific
data? Probably not; but from my perspective as a clinician, if
there's enough survey data that says for some people spirituality
and religion is very important and they would like, at least, their
physician to be aware of that dynamic in their life, I think that
is an important reason to address it.
Patient coping: In our interview with our
patients, we ask a lot about coping factors. I ask my patients
about family support, exercise, meditation, other ways that they
might cope. Why not, then, ask about spiritual beliefs that might
also help people cope?
we broaden the definition beyond religion, there's a lot of data in
the end-of-life field. In that field, people use what is called a
quality of life instrument. One of the domains is what's called an
existential domain that measures purpose in life and meaning in
life and acceptance of one's situation. When people are able to do
that, that correlates with having better quality of life at the end
of life, which is again a reason why, particularly around chronic
illness and death and dying, spirituality is important to
addition, there's some research about pain. Pain is
multi-factorial. There are physical dimensions to pain, but there
are also social, emotional, and spiritual dimensions. A group in
Calgary Hospital up in New York has developed a pain scale for
patients to use--these were chaplains that developed it, and
clergy--to identify their spiritual pain: Where is their spiritual
pain relative to their physical pain? Can patients use a scale to
describe these different types of pain?
There are some studies now--they are just
beginning; there's not a lot in this area--where people are looking
at the impact of spiritual distress on the perception of physical
pain as well. There is much anecdotal evidence from patients that
if their physical pain can be controlled, but if the spiritual pain
is not well-controlled, they are still in tremendous distress and
pain, and morphine will not take care of that.
Let's move to what we are teaching in the
courses. First of all, I mentioned that our definition of
spirituality is very broad-based. It's defined as a person's search
for ultimate meaning in life, which can be expressed through
religion but is much broader than that. It can be through other
types of spiritual beliefs, relationship with a Higher Power or God
outside of a religion, family, nature, rationalism, humanism, and
the arts: very, very broad.
the theologians in the audience, I know that raises a lot of
questions, but for us as clinicians, this definition is what's
applicable in the clinical setting.
outcome goal of the courses is that students understand that
spirituality may play a role in a patient's life and that we learn
how to respond to a patient's spiritual concerns. The students
learn about their own spirituality as a basis of their calling in
the profession, but also as a basis for self-care and how to
nurture that throughout their profession, and they recognize that
the care of patients involves more than just the physical, but also
the psychosocial and the spiritual.
we teach about spiritual care is, number one, being fully present
to our patients; number two, recognizing that we are not trained
spiritual care providers, so we learn to work in an
interdisciplinary model of care where chaplains are the ones who
are trained to provide spiritual care in most hospitals, and there
are other types of spiritual care providers such as spiritual
directors, pastoral care providers, and parish nurses.
talk about doing a spiritual history as part of a social history,
and there's an acronym I developed called "FICA." The focus of this
history, though, is not a religious history; it's to ask what gives
meaning to a person's life and whether they have spiritual beliefs
that help them cope with stress or what they are going through.
Find out how important that is, find out the community aspect, and
then be thinking about how we should address or take action on what
our patients have told us.
also teach ethical aspects. Proselytizing is not allowable in the
clinical setting. We make no bones about that. That is an absolute
in the courses that we teach: that chaplains are the spiritual care
providers; that physicians are not trained to get into lengthy
discussions about spiritual issues or religious issues with their
patients; that the focus on spirituality is more on the inherent
value that religion or spirituality gives to that person as a human
being, not so much on positive health outcomes.
terms of prayer, we recommend that physicians not lead prayer, but
request a chaplain to do that. However, if a patient requests a
physician to pray, that physician could stand by in silence and
allow the person to pray in their own tradition.
for the "A" part of the FICA, how we need to address it, one of the
options that we teach our students is just to listen and be
supportive. This is a time to listen to what's going on with your
patient, understand what dynamics might be playing in that
patient's life at the time, and, again, refer the patient to
chaplains and other providers.
patients will ask about yoga, meditation, and other types of
spiritual practices, and then there will be a lot of reflection on
past spiritual support practices. For example, if I have a patient
who says meditation has been helpful to me, or going to church or
temple or mosque has been helpful, and they stopped doing that and
feel a lot of stress, I might reflect that "In the past you told me
meditation, for example, helped. Where does that sit in your life
right now?" But it would not be prescribing religion to patients.
That would not be ethical.
conclusion, I think there's a tremendous amount of support for the
courses. It is controversial, but what we're talking about is the
inherent importance of the doctor-patient relationship.
of our definition of spirituality is that it's not just our
patient's spirituality, but it's our own. It's spirituality in the
broadest sense of that word that goes to our interaction with our
patients as compassionate human beings, that goes to our
interactions with others on the interdisciplinary team. So many of
us would actually talk about medicine as a spiritual practice.
BUTLER: Our next speaker is Dr. Cynthia Cohen, a Senior
Research Fellow at the Kennedy Institute of Ethics at Georgetown
University, also here in Washington, D.C., and a Fellow at the
Hastings Center in Garrison, New York. Dr. Cohen has published
widely on the issues of biomedical ethics and the role of prayer
and faith in health care.
COHEN: In contrast to some of our other speakers, I'm a
philosopher and a lawyer by training. I have worked in a health
care context, having taught medical ethics in three different
medical schools, gone on rounds, and having been an associate at
the Hastings Center, which is a medical ethics think tank in New
York. Now I am at the Kennedy Institute of Ethics here at
has the subject of prayer become such a compelling topic of
interest in recent years? It's hard to open a newspaper, listen to
the radio, without hearing something about the efficacy of prayer,
about studies that suggest that this is a novel way of looking at
patient care and helping patients to recover from illness. Yet we
know that prayer is not exactly a novel way in which to address the
needs of those who are sick. Praying for the sick is one of the
oldest religious practices in the world, engaged in by people
across a variety of religious denominations.
difference is that the new interest in prayer is trying to look at
it in terms of its efficacy. Is this something that can be used as
a treatment? You can understand where medical practitioners are
coming from because they don't want to use a medication or a
procedure on patients unless they are sure it's safe, unless they
are sure that it has some sort of impact.
way they usually go about this is through scientific studies. So
far, the studies seem to show that prayer in particular seems to
work on some patients. There are studies that show that prayer has
apparently been associated with improved health care outcomes for a
high proportion of patients in certain studies. However, other
studies show that prayer doesn't seem to have the same degree of
the basis of these studies, some commentators have said health care
practitioners ought to talk about patients' religious beliefs and
practices with them, and indeed ought to encourage them in the
practice of prayer, even get them going if they don't know how to
get started on their own.
Making it a routine thing for health care
professionals to delve into their patient's religious faith raises
certain ethical questions: Are these inquiries consistent with
professional ethics? Could they involve a violation of patient
privacy, as was believed in medicine for much of the 20th century,
as Dr. Koenig pointed out? Might some patients feel coerced into
responding to doctors' inquiries about their religious and
appreciate Dr. Puchalski's broader concept of spiritual beliefs. I
wonder, though, if I were a patient who was asked to talk about my
spiritual beliefs, if this would not be a synonym for religious
belief, but instead would bring to my mind implications of, say,
spiritualism, séances, or the Dalai Lama, who drew 7,000
people to the Washington Cathedral on the basis of his spiritual
would love to get into a broader conception of what doctors ought
to be addressing. I'm a little concerned about using the word
"spiritual" because of unintended associations that it would have
Might some patients feel coerced into
responding to doctors' inquiries in the way in which they think
doctors would want them to? Health care very much hinges on what
the physician thinks of the patient. The physician seems to have a
lot of control over the hospital setting.
Should doctors or nurses initiate prayer
themselves as a means of helping patients to improve? The risk that
patient privacy, patient autonomy, and patient well-being might be
subverted by professional proselytizing or inadvertent or direct
coercion looms over calls to physicians to inquire into religious
beliefs to their patients.
study that brought to the fore the question of whether medical
science can prove that prayer works was carried out by Dr. Randolph
Byrd in 1998. He was a cardiologist who looked at patients in a
cardiac care unit. He separated patients who had suffered heart
attacks into two groups. There were those in the coronary care unit
who got standard medical care. Then there were others who, in
addition, got prayer from anywhere from three to seven born-again
found that the patients who were the subjects of prayer needed
fewer antibiotics, experienced a lower percentage of congestive
heart failure, and were less likely to develop pneumonia. He
concluded that "Intercessory prayer to a Judeo-Christian God has a
beneficial effect in patients admitted to a coronary care
Since then, other investigators have
mounted studies to display the efficacy of prayer in that setting
and in other settings, and the results have by and large been
positive, but not altogether. Some do seem to show that prayer
works and makes people better, but there are others that give
reason to be less sanguine about this.
instance, when psychiatrist Scott Walker tested whether prayer
could speed the recovery of individuals who were addicted to
alcohol, he found that those who were prayed for were no more
likely to recover than those who were not. When he asked his
patients about this afterward, they said, "Well, I had people
praying for me in my family, and frankly, I behaved very badly to
them when I was drunk. They probably were sending negative prayers
about me to God, and that's how your study was affected and how the
prayers were answered."
it possible to test the efficacy of prayer scientifically? What
does the standard, randomized, double-blinded controlled study in
science have to say about this? In this sort of study, patients who
seem to be alike in significant respects are assigned by chance to
one of at least two groups. In one group, they're going to get the
kind of treatment that's under study. The control group is going to
get placebo treatment of some kind. The study is said to be
double-blinded because neither patients nor doctors are told who's
in either group until the conclusion of the study.
Could prayer be subject to this
experimental approach? Patients would have to be divided into at
least two groups: patients who were receiving genuine prayer and
patients who were receiving no prayer--or, if you want to follow
the standardized model, patients who were receiving placebo prayer.
How could investigators ensure that one group was receiving prayer
and the other group none? How could they verify the presence or
absence of prayer? How could they coax the patients in the study
who were receiving prayer not to pray for themselves? How could
they get people all over the world who are praying for the sick on
a daily basis not to pray for the people in this particular study?
It just doesn't seem possible.
Moreover, the design of these studies
requires uniformity and careful empirical measurement. Wouldn't you
have to use the same prayer for every single patient in this study?
The Byrd study said praying to a Judeo-Christian God was
efficacious. Yet you wonder, would it be effective and appropriate
for a Muslim or a Hindu patient? Do we need to investigate and find
some sort of interdenominational prayer that would be effective?
This could create a problem for Zen Buddhists, who don't tend to
appreciate the value of spoken prayer. They are more involved in
wordless meditation. How would we address their medical needs,
then, if we were trying to study prayer?
you are measuring drugs in medical studies, you look at the dose
response effect of that drug. You look at whether a standardized
amount of medication evokes the uniform response across the board,
or whether a larger dose increases the desired effect. How could
researchers similarly quantify the dose response of effective
prayer and evaluate whether more is better? What amount and degree
of intensity would this require? What outcomes would be required to
distinguish prayer as the sole cause of improved patient
Surely, when you've got a very firmly
defined outcome such as death, you can look at studies involving,
say, pancreatic carcinoma or rabies or smallpox--diseases with
almost 100 percent mortality--and decide whether the outcome has
been changed by prayer. But what about outcomes other than death?
Should we investigate restoration of motor function after a
paralytic stroke in patients? What about return of a normal
coronary angiogram in those with higher evidence of significant
coronary obstruction? What about cure of a cold? How serious and
how discrete should the outcome be to prove that prayer alone had
Finally, you'd always get an argument
about what the study results proved. People who found that prayer
seemed to work, for example, would get an argument that they hadn't
included enough patients in their studies. The same would be true
if the reverse were found; if prayer were found to be
inefficacious, there would be objections from those who thought
that it was efficacious.
Basically, what I'm suggesting is that the
effort to test the efficacy of prayer is grounded in an
impossibility. Prayer is not the sort of practice that can be
tethered and measured, and nobody can sincerely practice a
faith--certainly not the Jewish, Christian, or Muslim faiths,
theistic faiths--for their health benefits. Theists engage in
prayer because that's where they encounter God. They present
themselves as needy, but they don't encounter God solely to get
their needs met. They come to meet God, their most fundamental
short, the theistic traditions don't view prayer as a sure means of
getting God to give humans their way. This doesn't mean that we
ought to abandon prayer for the sick. Surely, in theistic
traditions, such prayer is embraced as recognizing human dependence
upon God. That God answers prayer, though, is a corollary of belief
in God, not the test for the vindication of that belief.
Let's consider other studies that don't
focus on prayer, but look at attendance at religious services,
other religious and spiritual practices that have a beneficial
impact on the way patients respond to sickness. Some studies have
found that religiosity and spirituality are associated with
improved physical well-being, including lower blood pressure,
decreased levels of pain, a higher likelihood of surviving cardiac
would contend that these studies in themselves, even if they are
found to be in accord with scientific methodology, would not
justify a claim that health care professionals ought to delve into
their patients' religion to improve their health. There are many
factors, such as patients' movie-going habits, their selection of
reading material, their choice of a pet, that can have a positive
effect on their health, but we don't consider these as within the
domain of usual professional inquiry.
think that the reason it's appropriate for health care
professionals to open the door to talking about religious beliefs
with patients is because patients in individual cases may want them
brought into consideration as important to the way they make health
care decisions. Some patients will indicate this openly in the
course of certain conversations with doctors as they enter into
long-term care with them. Other patients will not, though, because
they are concerned that this is not something that doctors talk
about, and I'm not going to go that way because I don't want to
offend my doctor.
There's a third group of patients who want
to have nothing to do with this. In order to accommodate these
patients, it would seem that what we ought to do is have physicians
ask very general questions--What's important to you that you think
I ought to know about as we enter into your health care? What are
your sources of support?--and to take it from there, see what kind
of answer physicians get, and perhaps move into religious belief if
this seems to be important to a particular patient, or artistic
concerns if this seems to be what's important to patients.
There's a very large issue at stake.
Basically, religion and medicine have been closely linked
historically. Each has been seen as an important way to meet human
needs. Are both medicine and religion to be regarded as ways of
delivering comprehensive human well-being?
practice of religious faith is directed towards meeting the deepest
and most comprehensive needs of people as religious practitioners
understand these to be, and in that very broad sense, it may be
said to be therapeutic. It certainly is responsible medical
practice to consider how religious convictions affect patients'
both medicine and religion are in danger of distortion if we don't
understand their distinctiveness. It's a misunderstanding of
religion to view it as detachable from a commitment to a way of
life, from religious belief, as if it could be reduced to a
treatment modality or engaged in simply for the sake of lowering
as surely, it's a distortion of medicine to see it as capable of
delivering comprehensive human meaning or fulfillment. Medicine is
limited not only by human ignorance and error, but ultimately, by
mortality. Every patient is lost in the end, and not even the best
medical care can stave off death forever or provide a means of
living bravely and well with that reality.
BUTLER: Our final speaker, Dr. Richard Sloan, is Professor
of Behavioral Medicine in the Department of Psychiatry at the
College of Physicians and Surgeons at Columbia University in New
York. He is also chief of the Department of Behavioral Medicine at
the New York State Psychiatric Institute and Director of the
Behavioral Medicine Program at the Columbia Presbyterian Medical
Center in New York City.
Sloan's principal work focuses on identifying the autonomic and
nervous system's mechanisms, linking psychological risk factors
such as depression, hostility, and anxiety to heart disease. In
addition, he and his colleagues have recently explored and
criticized the purported links between religion, spirituality, and
health that have appeared in popular and medical publications. He
has identified, in his view, very significant ethical problems
associated with making religious activity an adjunctive medical
procedure--some of the issues that Dr. Koenig raised at the very
end of his presentation.
SLOAN: Let me begin by thanking the Heritage Foundation
for assembling this panel. Although, both in print and in public,
I've disagreed with a number of assertions that you've already
heard, it's an honor to be on the same panel with these
participants. These are among the best people in the field.
me also begin by saying that nobody disputes that for a great many
people in the United States, religion and spirituality are
enormously important. Correspondingly, nobody disputes that for a
great many people in the United States, religion and spirituality
provide comfort in times of difficulty, whether it's related to
illness or otherwise.
question for us is whether medicine and physicians can add to that.
There are a number of reasons to suggest that the answer is that
they cannot. As a number of the speakers have already indicated,
it's a very complex problem; and as H. L. Mencken said, "For every
complex problem, there is a solution that is simple, neat, and
my view, tying religion and spirituality closely to health outcomes
is misguided for a number of reasons. Those reasons are
empirical--that is, the quality of the evidence; practical--what
actually happens in the clinical setting; ethical; and theological.
Let me go over each of them.
empirical evidence is, in my view, far less solid than Dr. Koenig
believes it is. The most current comprehensive review was published
in January of this year in The American Psychologist. Lynda Powell
and colleagues reviewed nine different domains of evidence
purportedly linking religious and spiritual beliefs to health
outcomes. They include examining the relationship between
attendance at religious services and mortality; recovery from
coronary artery disease; prevention of coronary artery disease;
prevention of cancer; recovery from cancer, stroke, et cetera; and
immune function. Of the nine, only one, in their view, had strong
evidence in support of it. That was the link between self-reported
attendance at religious services and reduced mortality.
that area, there are a number of good studies now, although there
were some weak ones previously. The problem with that evidence is
we don't have any idea what the self-reported assertions of
religious attendance mean.
Almost all of these are based on surveys
that are conducted. Patients are interviewed either by phone or in
person and asked to report how often they go to church or
synagogue; for example, once a week or more than once a week, a
couple of times a month, three times a year, never, et cetera.
Garrison Keillor commented that anyone who believes that sitting in
church makes you a Christian must also believe that sitting in a
garage makes you a car. That illustrates the vagaries of what
sitting in church means. It means a great many things to a great
many people, so we really don't know what it means.
Moreover, there is persuasive evidence
that when data are collected in interview format, either in person
or by phone, respondents systematically inflate their reports of
church attendance. There are a number of publications in the
sociological literature that suggest that this happens in order to
satisfy what researchers refer to as self-presentation bias. The
respondents want to look better to the interviewer. It doesn't
happen on paper-and-pencil questionnaires, but it does happen in
the evidence linking religious attendance and health outcomes is
weaker than it seems because it is very likely that the reports of
attendance are inaccurate. That's one empirical consideration.
other empirical consideration was illustrated very nicely by Dr.
Cohen, talking about the Randolph Byrd study, which is the first
major study of the impact of intercessory prayer; that is, the
prayer of one group of people on behalf of others. The Byrd study
measured 29 different outcome variables. Dr. Cohen mentioned a
turns out that only six of the 29 showed a benefit for the prayer
group. Moreover, of those six, they were not independent. So, for
example, the patients who received the intercessory prayer had
fewer cases of pneumonia and fewer cases of newly prescribed
antibiotics. Those are the same thing. You prescribe antibiotics
for pneumonia. Moreover, the patients who received prayer had fewer
cases of heart failure and fewer new prescriptions for diuretics.
Again, the same thing; you prescribe diuretics for heart failure.
So they are not independent.
approach to the analysis to these 29 variables is epitomized by
physicist Robert Park's example of the sharpshooter's fallacy. Park
is the former president of the American Physical Society and a
critic of junk science. He wrote a book a few years ago called
Voodoo Science, in which he described the sharpshooter's fallacy.
The fallacy is that the sharpshooter empties the six-gun into the
side of the building and then draws the target. That's what happens
in a great many of these studies. A slew of variables are
collected, and then researchers conduct a large number of
statistical tests and say, "Aha, there's something" because one of
these tests meets the criteria for statistical significance,
ignoring the other statistical tests conducted.
on empirical grounds, the evidence is much weaker than we're led to
believe. In these days of interest in promoting evidence-based
medical services, that's a serious problem.
there are practical considerations. Earlier this year, in The
American Journal of Public Health, a paper was published indicating
that if practicing physicians in the United States followed all of
the recommendations of the U.S. Preventive Services Task Force,
they would spend 7.4 hours per day. That's before they did anything
else: 7.4 hours per day.
question I have is, should we be spending time exploring patients'
religious and spiritual beliefs when we already know that, even
today, not enough physicians ask about smoking. Not enough
physicians ask about diet and nutrition. Not enough physicians ask
about exercise. Not enough physicians ask about depression and
stress. All of those are demonstrably related to deleterious health
outcomes. With a limited amount of time, what do we want physicians
to spend their time on?
Those are some of the practical
considerations. Then there are the ethical considerations. We have
focused on three. The first is the risk of manipulation or
coercion; the second, invasion of privacy; and the third, actually
me talk about manipulation. The nature of the physician-patient
relationship is asymmetrical. Patients seek the medical expertise
of physicians, and both physicians and patients assume that the
patient will follow the recommendations.
That's the nature of any relationship in
which someone seeks the services of an expert. If you seek the
services of a tax accountant, you expect that you are going to
follow the recommendations of that tax accountant, and the
accountant expects the same thing. In any relationship between an
expert and somebody seeking expertise, that's the assumption.
That's fine in the medical setting as long
as the physician's recommendations derive from his or her medical
expertise. But when physicians depart from their expertise to
promote other agendas, it runs the risk of manipulation. It runs
the risk of promoting a potentially coercive agenda and, as such,
is a threat to religious freedom.
second concern is privacy. There are a great many factors in our
lives that are demonstrably linked to health outcomes but that are
regarded as out of bounds to medical practice. The best example is
marital status. There is an abundance of evidence suggesting that
being married promotes greater longevity and is good for your
health. There's more recent evidence to suggest that it may depend
upon gender. It may pertain to men and work in the opposite way for
Regardless of which direction it works, we
don't expect physicians to make recommendations about marital
status to their patients because of the reputed health benefits. We
don't expect physicians to address a male patient and say, "Bob,
I've got this wealth of evidence here that suggests that being
married is good for your health. You're single, and I think you
ought to get married because it's going to be good for your
reason we don't do that is because we regard marital status as
personal and private and out of bounds of medicine, even if we can
show that it's related to health outcomes. That is abundantly true,
and probably more so, of religious pursuits, which for a great many
people are personal and private.
third ethical concern is actually causing harm. Even in these days
of medical consumerism, patients still confront age-old folk
wisdoms about personal and moral responsibility for adverse health
outcomes. Because of the problems in considering anecdotes, in the
empirical setting, I tend to stay away from relying on anecdotes;
but when illustrating an ethical point, I think an anecdote is
want to recount an experience that I had early in my research
career when I was interviewing a young woman who was awaiting the
result of a gynecological biopsy. She was in a semi-private room.
The other woman in the room was also awaiting the results of
gynecological biopsies. Of course, they were separated only by a
thin curtain. The other woman had members of her family and friends
While I was interviewing my patient, the
other woman's biopsy result came back, and it was negative. Her
father exclaimed to nobody in particular, "We're good people; we
deserve this." Now, that's a perfectly reasonable thing for the
father of a potentially gravely ill young woman to say. It's an
expression of relief. It's fine.
was the young woman I was interviewing supposed to say to herself
when her biopsy came back positive? Was she supposed to say, "I'm a
bad person; that's why I got cancer? I haven't been sufficiently
devout; that's why I got cancer?" It's bad enough to be sick. It's
worse still to be gravely ill. But to add to that the burden of
remorse or guilt about some supposed failure of devotion is simply
unconscionable. That's what you get when you make suggestions that
religious activities are associated with beneficial health
Finally, there are theological
considerations. Dr. Cohen actually touched on a number of these.
Many theologians are extremely concerned about suggestions that
religious beliefs and activities are treated by medicine in the
same way as prescribing a low-fat diet. In what way are religious
activities like taking a beta-blocker or consuming a low-fat diet?
It seems to me that such suggestions demean the transcendent
meaning of religion and are actually sullying what religion is to a
great many people.
me conclude by reiterating that nobody disputes the value of
religion and spirituality in bringing comfort to a great many
people in times of distress, whether it's related to illness or
otherwise. The question, it seems to me, is whether medicine should
be involved in this, whether physicians should be involved in
see it, the answer is generally "no."
Q & A
BUTLER: I want to thank all of our panel for excellent and
very provocative presentations. Let's start with questions and use
that as the basis for discussion.
SPEAKER: I'm surprised that no one
mentioned the religious denomination of Christian Science. I'm not
a student or a practitioner, but it's my impression that they are a
fairly successful Protestant denomination who put practically all
of their health eggs in the prayer basket.
of you, I'm sure, have more knowledge of Christian Science
practices than I do. I'd like to hear something about it.
COHEN: I don't think you're going to find many Christian
Scientists coming to physicians' offices or to the hospital, just
because of their religious beliefs. I think that when you have
children involved, this becomes difficult. Some states have passed
laws saying that a child who falls seriously ill cannot be
prevented from receiving medical care because the parents are
Christian Scientists, but other states haven't. So, in a sense,
within the health care setting, it's often not a live issue.
SLOAN: Christian Scientists range in their beliefs from
either completely abstaining from medical care to receiving care
just like you and I receive care. So there's a wide range. Some
earlier studies published in JAMA, and then in some of the public
health reports, indicated the Christian Scientists did not have as
good health as those in the general population that they compared
them to. They had greater mortality when they compared the length
of their lives in graduates from certain colleges. They had worse
outcomes from cancer.
PUCHALSKI: I would like to address that question, but
actually broaden it a little bit because it addresses a very
important point--something, again, that we teach in the medical
schools. I will defer to the exception of children, but regarding
adults, I do have some patients who are Christian Scientists and
will accept some limited amount of medical treatment and actually
will see me because, for the most part, I will respect that and not
give additional treatment that they are not comfortable with.
have a lot of colleagues I work with who are Christian Scientists
and who do not seek traditional medical treatment. But beyond that
is the importance of respecting where a patient is. We could even
broaden that question to accepting any kind of treatment.
our interactions with patients, as Dr. Sloan would say, we may be
experts in certain things, but I think unlike other types of
professions, we recognize that we're not experts in everything.
Even when it comes to recommending treatment, patients will bring a
variety of different beliefs to us with regard to whether they're
going to accept that or not. Traditionally trained physicians by
and large have an agenda and a focus to try to get the patient to
accept a particular treatment.
novel thing that we're trying to do in the courses is to say don't
necessarily have that agenda. You have a recommendation, but if
your patient has a strong belief--it doesn't even have to be
religious; it can be other types of belief--about whether they're
going to accept a treatment or not, you need to respect that and
not try to force that belief out of that person in order to have
your agenda met.
Christian Science is one. Another is the
Jehovah's Witnesses. I had an oncologist at a conference yesterday
ask me how in all good conscience I could not give transfusions to
a Jehovah's Witness. Am I not violating my ethical principles as an
expert physician who knows that transfusion would alleviate a
serious life-threatening anemia? I say it's just the opposite. I
think it's unethical to force something that violates a person's
SPEAKER: Dr. Puchalski, as I understand
it, you are involved in a development of some sort of ethical
norms, or at least in the investigation of it. I understood you to
say that with respect to physicians, if they are asked to pray with
a patient, that they could then stand silent. Is that a suggestion,
then, that the physician who does overtly pray with the patient at
his or her request is somehow deviating from the norm and is
subject, possibly, to a liability of some sort or a punishment?
PUCHALSKI: To my knowledge, there's been one lawsuit
around that, but I'm not certain of the details. I was never able
to find documentation of that.
me back up to what you said about prayer. Generally speaking, what
many physicians feel and recommend about prayer goes to what Dr.
Sloan very well described as the power differential between doctors
and patients. In anything that we do, be it prayer or any other
kind of conversation we have with our patients, we have to be very
careful that we're not being coercive.
Let's say a patient asks me to pray with
them, and I say, "Fine, I will do that," because that's a very felt
need; that's an important question the patient asks me. But then I
lead it in my tradition. Am I not risking imposing my tradition
onto that patient?
Second, there is a lot of training that
goes into leading prayer. I might be able to lead prayer in my
tradition, in my faith community, but in terms of being someone who
learns the skill of asking what the person wants to pray for, what
does it mean in the context of their beliefs? Chaplains and clergy
are trained to do that. We are not. That's why the recommendation
against physician-led prayer is very strong, because, number one,
we're not really trained to lead prayer and, number two, it opens
that door of possible coercion.
many of us recommend standing by in silence is that when a patient
requests prayer, that's a very intimate request. To have someone
turn around and say, "No, I'm not going to do that" could be very
rejecting. So we recommend an alternative, which is maybe stand by
in silence or invite the chaplain in if you're in a hospital to
lead the prayer and be present at that. Then your patient doesn't
feel that sense of abandonment and rejection.
There are exceptions, though. There are
physicians who, for their own moral, ethical reasons, feel very
uncomfortable about participating at all. They don't believe in
prayer. They think they're lying if they pray with a patient. We
would not recommend that physicians do something that goes against
their own moral principles.
There are also exceptions where physicians
have long-term relationships with their patients, where, in many
parts of the country, the physician actually attends the same
church that the patient does and they know each other in a social
context. In that case, more active prayer may be appropriate.
there are going to be some exceptions, but these are general
principles that we discuss in order to protect the patient's
privacy and not to feel that that person is going to be
KOENIG: Christina and I are generally in agreement, but
not entirely on the issue of doctors praying with patients. I think
if the physician takes a spiritual history and knows that this
patient is religious and that they are praying, and in particular
if the patient requests it and if the physician is of the same
religious background as the patient, and if the situation warrants
it--if it's a serious condition such as the diagnosis of cancer or
disability, for example, or recent stroke--I think it's permissible
for the doctor to actually say the prayer.
That's just my opinion. I have prayed with
patients. I don't do it very often. I do it in the context of a
relationship. In the last two to three years, I've prayed with two
or three patients. I've known those patients for five to seven
years. I know they're religious. I know they cope through their
faith. I know that's very important to them, and they have asked
me, and when I've done it, I've just seen amazing things done.
not a long prayer. It's a short prayer, just a comforting prayer.
In hospitals, you see the cleaning women praying with patients. You
don't need a whole lot of training to pray with somebody. We pray
with our families, particularly if you're of the same religious
background and it's clear that it would bring comfort to this
Sometimes patients don't recognize that
their doctor would even be open to this. I've given some talks in
churches, for example, and they said, "Well, I'd be a little
reluctant to ask my doctor to pray with me. I don't think he'd be
open to it." I guess maybe the doctor could say something like,
"Should you ever want to pray, I'd be open to that."
Leave it up to the patient. The patient
doesn't have to respond, but at least allow this information to the
patient so that they know this is something they can talk to their
doctor about, and if they want him to pray with them, he can. This
is not something you can do with every patient. You have to be
extremely sensitive because these are very deeply, personal,
private issues that have to be respected.
SLOAN: Dr. Koenig's remarks illustrate one of the concerns
I have: that is, if I understood you correctly, if it's a serious
matter, then it might be acceptable. The assumption is that the
physician is going to make a determination about what's a serious
matter in the mind of the patient. The patient is asking for the
physician to pray, and the physician is going to act as an arbiter
of that value, to determine whether this is a situation which
merits prayer with the patient or not.
seems to me that physicians are completely ill-equipped to make
those determinations and should simply not get involved. The
patient should be free to do whatever he or she wants. But if a
physician is going to start making decisions about what's an
appropriate religious belief to have and what's an inappropriate
religious belief, that's a very dangerous thing.
COHEN: Not that I completely agree with Harold, but just
to pursue this a little bit further, I think Harold was talking
about not so much the situation regarding prayer, but clearly that
there are some circumstances that we make decisions on.
patient's parent just died and they're sitting there crying and
it's a very serious issue for them, or if the patient says this is
serious, or they're actively dying, we can sit here and talk about
the research and the ethical principles, but there's not some book
that we can follow and a script that we can follow. We lead from
our experience, our heart, and our judgment call.
think physicians are actually equipped to make the judgment call of
whether something is serious or not. I think what you were trying
to say is: Is it serious enough to warrant my leading a prayer? I
think that's what I heard you say.
SLOAN: Oh, no. It seems to me the assertion was that if
the physician deems it a serious matter, then he or she could
accede to the demand; otherwise, not. If the patient has the
sniffles and asks for a prayer, is that a situation in which the
physician then makes a decision: "No, this is not serious enough; I
won't accede to the request?" Or if the patient is dying of cancer,
what gives the physician the right to determine when a religious
request is sufficiently serious? It seems to me, nothing.
KOENIG: I would agree. When I said "serious," I meant
serious in the mind of the patient. That's what I would have
COHEN: However, if a patient has the sniffles, and they
turn to me and say, "Doctor, will you pray with me," that's a very
different situation when the patient makes that request. That does
happen in a clinical setting. What are we to teach our physicians?
Not to respond at all or to turn red and panic and run out of the
room--which does happen--and then jeopardize the patient's
reaction, feeling that they somehow opened themselves up and now
the physician has rejected them?
That's why I'm recommending that much
kinder or balanced approach, which is to say, "If that's important
to you, you are welcome to do that," and then maybe to stand by in
silence and allow the person to do that.
PUCHALSKI: The other side of the coin is that we all know
stories of physicians who have responded to such requests by being
overbearing and very assertive and very coercive. We want to try to
avoid that as well.
BUTLER: I have a quick question on the methodology. Maybe
both Dr. Sloan and Dr. Koenig could comment on this.
of you alluded to the issue of whether religious practice may
involve other activities for which there may well be some evidence
that this is connected to improved recovery and so forth. For
example, people who have a strong religious activity may have a
very strong support group. Many people come to visit them. They
have a community that they know is caring about them. They may have
more confidence about recovery.
there any evidence from the research that there may be some more
demonstrated characteristics of behavior that overlap in many
instances with religious activity that might in fact be better
explainers of this connection or otherwise?
SLOAN: Certainly, certain religious denominations
proscribe certain risk behaviors: cigarette smoking, consumption of
meat, caffeine. The epidemiologic studies that compare, for
example, Seventh Day Adventists with other religious denominations
often show health advantages to the Seventh Day Adventists. It's
purely attributable to their dietary habits. Anybody who consumes
the same diet will have the same health benefits.
if the concern is that religious practices promote certain
risk-reducing behaviors, I would certainly agree. But there are
many vehicles by which one can modify health behaviors. It's not
just becoming a Seventh Day Adventist, for example.
KOENIG: I think that religion provides a package of things
that are hard to get elsewhere. The effect that religion has on
health is mediated through such mechanisms as the support it
provides people and the commitment of not only receiving support,
but also giving support to others.
think this is part of the way religion influences health. Also, by
affecting health behaviors in terms of those doctrines that we
don't like to listen to--the "thou shalt nots"--that you're to
respect your body; you're not to drink heavily; you're not to
smoke; you're to live a healthy life style by showing respect to
is how religion does it. I don't think that we're studying some
kind of miraculous effect here. I think what we're looking at are
the effects of the social support, the better mental health, the
ability to cope better, the living of a healthier life, the making
of better decisions. This "results" in better health.
have to admit to both Cynthia and Richard that the intercessory
prayer studies, in my opinion, are worthless because they are not
built on any scientific paradigm, and also, theologically, they
have serious problems. So we try to avoid that particular area as
much as possible.
SLOAN: Again, the issue of concern is the potential for
physicians to become arbiters of what's appropriate and not
appropriate religious behavior.
Koenig is absolutely right. There are many religions that provide a
faith community, that provide social support and proscription of
risk behaviors. But there are other religious traditions that
promote the use of psychoactive drugs, for example, or snake
handling. Are we going to make decisions about those as
inappropriate religious practices? Who are physicians to make those
SPEAKER: Dr. Sloan, you may want to
share the same experience that the author Franz Werfel may have
experienced. Beginning in 1940, he was an author escaping from
Germany. He felt the best way to get out was over the French border
into Spain and found himself delayed by train in a small town in
southern France called Lourdes.
you go to Lourdes, you will find there something called the Medical
Bureau. It is made up of doctors from all over the world, all
dealing with the matter of, from April to October, people of all
sorts of denominations coming to Lourdes with intercessory prayer
with respect to the miracles and miraculous cures that have taken
place there. Four million people a year.
Since 1858, there have only been 67
documented miracles in Lourdes, but millions come there per year.
One would have to ask the question, why do they come there? It has
to do with their understanding of the value of prayer and that, if
there is a cure, there are very specific medical examinations made
with respect to the role that prayer played with respect to the
cures that are there.
Franz Werfel said, for those that believe,
no explanation is necessary. For those who do not believe, no
explanation is possible.
SLOAN: Precisely. That's the difference between faith and
science. They are independent domains. Who would want to disabuse
people from going to Lourdes or anywhere else in the service of
their religious beliefs? Nobody. But that's not science; that's
KOENIG: Everything about Lourdes suggests that they are
connected, specifically connected.
SLOAN: Well, I don't believe there's any evidence.
SPEAKER: I'd like to ask Dr. Sloan: I'm
a volunteer chaplain. On one hand, I resonate to some of the things
Dr. Puchalski was saying. On the other hand, I've been what I call
a professional cynic as a systems analyst and mathematician in my
professional life, and I sometimes feel a little bit like Dr.
you say they are completely independent, what I'm hearing is the
dilemma that modern medicine faces, and doctors face now, that
simply brings them together in your life. As a chaplain, I was
thinking, "Yes, it's better for the doctor to call the chaplain
when the patient wants a prayer." But as you pointed out, the first
time that this patient is going to run into this situation is in
your office, and you haven't got a chaplain.
that mean that it is not appropriate to start preparing doctors for
dealing with that in whatever way is right for them, which is
probably different for every doctor? Some doctors may be
comfortable in asking what the patient's spiritual background is
and feel comfortable in praying. Others may say, "I'm of a
different faith. Why don't you pray?" Others may avoid it
doctors need to be prepared for it. It is part of practicing
medicine now, no matter how you look at it. You've got to deal with
that, so why not train for it?
SLOAN: Of course, you're right. Physicians have to be
prepared to deal with it, in the same way that they have to be
prepared to deal with any areas in which they lack expertise. When
you see an internist and you have a cardiology problem, the
internist refers to a cardiologist, who has expertise that the
the same way, an internist who is confronted with a patient who has
religious or spiritual concerns ought to avail himself or herself
of the services of a religious professional, a member of the
clergy. I don't mean to suggest in any way that these are not
important matters to patients and that they're not important
matters to physicians.
question is whether physicians are equipped to handle them. Are
there ethical concerns about the way in which physicians address
these matters? Even if coursework were universally available and
thorough, it would pale in comparison to the training that
professional clergy receive.
These are complicated matters.
Fortunately, we have professional clergy who are skilled at these
PUCHALSKI: Richard, I agree with a lot of your concerns.
You mentioned that physicians will bring these issues to our
office, and that's one reason that we should be able to be
responsive to it, which, of course, I agree with. I think we need
to go one step further and make patients feel comfortable and open
to being able to bring up those issues if they are there. That's
why I take it a little bit further and say we should do at least an
actually differ a little bit with Cynthia in that I think we should
use the word "spiritual," because if I ask as a physician what
gives your life meaning, people won't necessarily think doctors are
open to spiritual or meaning issues. Even though those issues are
there, they may not feel open. So it's an invitation more to bring
up these issues.
Second, on your comment about chaplains,
Richard, again, I agree that we are not training doctors to be
chaplains. But just like with the rest of our history-taking, we do
teach people how to ask sensitively about marital status, sexual
history, domestic violence questions, et cetera. We are not experts
in those areas, but we teach our students to refer.
That's why I'm hoping chaplains are
getting more and more referrals as a result of these courses.
KOENIG: Family physicians do have to check the heart and
check the blood pressure to determine if a cardiology consult is
warranted. Therefore, I think the spiritual history is a necessary
part of identifying the issue.
COHEN: I just want to clarify one thing. Richard mentioned
the case where one patient overheard the reaction of a relative to
a diagnosis or a test of a particular condition. The fact is that
that relative's response in terms of most theistic traditions was
totally inappropriate. No theistic tradition would teach that this
patient deserves to be cured and this patient does not.
physician has to be equipped at some very basic level to be able to
respond to the patient overhearing this. That person didn't really
understand what's at issue theologically. I'm not equipped to go
into detail about it, but I can understand how that response would
bother you, and if you'd like, I can get a chaplain to come in and
talk to you about it.
SPEAKER: I have two quick questions. The
first one is, addressing your issue of physicians making these
judgment calls, what would the ramifications of discrimination be?
The second is a time issue. A short prayer is one thing, but
different rituals could extend beyond that. What are we talking
about in terms of other patients who might need their physicians
for the actual medical purposes?
KOENIG: I'm happy to speak about the time issue. This does
have to be done in addition to what the doctor does in taking care
of the patient. He can't take a spiritual history and not take the
blood pressure. So it does add some time. The question is: How much
There has recently been a study--and it's
not published yet, so I'm a little bit reluctant to talk about
it--that looked at how much additional time it took to take a short
spiritual history. It's not more than two minutes. So it is adding
two minutes to whatever the doctor is doing. The doctor would do
that not in a 10-minute office visit, usually. He'd probably do it
in a history when they're admitted to the hospital, when they have
more time with the patient.
SPEAKER: But beyond that, what about the
KOENIG: When you are getting involved in rituals with
patients, you have to be extremely careful. The only one I can
imagine is a short prayer if you know the patient and the patient
wants it, and you know this would bring comfort to that patient,
which even then is done with some degree of trepidation.
PUCHALSKI: To follow up a bit on that, the spiritual
history that I teach does take a little less than two minutes. But
if you think about everything else that we do in the context of all
the questions that we ask, the domestic violence, the
hobbies--there's a huge number of things.
the overall scheme of what we teach medical students is the need to
use your judgment as to what to do with the information that
patients are giving us. Let's say we're doing a global depression
assessment. We do a very quick depression assessment with our
patients. If that person is depressed, we're not going to go on
with the rest of the exam. If that person is acutely depressed, we
are going to respond to that.
Similarly, with the domestic violence
question, if that person is a victim of domestic violence, we're
going to need to adjust what we're doing in order to respond to
that particular need. With the spiritual history, if something
comes up that requires a lot more discussion or referral to a
chaplain or something that the person just wants to talk about
more, we may need to defer other parts of the history.
That's why the system of health care we
have right now does not meet patient's needs, because it tries to
pigeonhole people into 10-minute visits. We should not teach to a
bad system. We should teach to an ideal and then try to teach our
students to work around the current problem.
SPEAKER: The other side of this is that,
for someone who is in a vulnerable time and has a lot of faith,
their faith is completely at question, whether you the doctor know
it or not, as they hear this news. The physician who has not
explored his or her own spiritual tenets, by rejecting the
patient's inquiry or struggle, is in effect impacting their faith.
That has an impact on their healing or on their own faith because
of the authority position the physician is in.
COHEN: I think the kinds of discussions that Christina
carries out in medical school teaching do stimulate
physicians-to-be to ask themselves, "Where do I stand with regard
to this?" If a physician is not somebody who adheres to a
particular faith tradition, that physician certainly should realize
that they are going to have an obligation to be aware that patients
may very well consider this very important and ought to learn how
to address those patients, how to help them, and how to learn what
the limits of their own expertise are.
think that's one of the important things that Richard is pointing
out. That does concern me: that physicians may go well beyond what
their level of training is, what their level of expertise is and
background. Granted, some are well-trained to do this. There are
some physicians who are also trained in chaplaincy or who are
priests or brothers. But that's the rare exception. Most physicians
though they may be exemplary in their own religious life, there is
a line beyond which I would contend they should not go. They should
open the door; understand how patients' religious beliefs affect or
might affect their medical care; put aside their own disbelief, if
that's the case for them; and then try to understand where to go
next with this patient, whether this patient needs special help,
whether the chaplain in the hospital is any good.
been in situations where doctors would not refer patients to the
chaplain in their hospital because they felt this would be
extremely damaging. I have also been in on scenarios where doctors
would not refer patients to their own ministers for the same
reason. The minister's interpretation of the religious tenets of
their tradition, they feel, is very severe and could be damaging to
the patient, and then they get the chaplain in.
there's no universal answer to these questions. The concern is
whether this could be coercive or harmful to the patient and how to
SPEAKER: I was wondering if each of you
could just quickly define prayer. There's petitioning; there's
affirming a good God; there's a God of fear. Could each of you
quickly define what sort of prayer you are referring to in your
KOENIG: Prayer is what the patient defines as prayer,
because that's the way many of these studies are done. The patient
is asked, "How frequently do you pray?"
PUCHALSKI: I think prayer, again, comes from the patient's
definition, but my general definition would be that it's an
encounter with God, or however a person understands that.
COHEN: Very often in these studies, it is considered
intercessory prayer, a particular kind of prayer where you are
asking God for something. In traditional theistic religions,
there's often a pattern that is suggested that you follow.
Intercessory prayer often comes third, after adoration and
thanksgiving. In the studies, it seems to be intercessory that is
SLOAN: I can't add anything to what Dr. Cohen
BUTLER: I want to thank the panel very much for the
excellent presentations, the thoughtful discussions. I don't think
we've exactly resolved the question we posed, but I think in
discussing it, we've learned a great deal.