When medical meets spiritual

D I M E N S I O N S

O F

D O C T O R I N G

When Medical Meets Spiritual Yi-Kong Keung, MBBS, FACP, and Richard McQuellon, PhD

Human beings have complex personal, psychological, sociological, and spiritual dimensions. The spiritual dimension deals with the essence of what lies “beyond the physical or biological being of a person,” with what is closely related to the human search for the meaning and purpose of life. What is the meaning of life? What is death? Is there a God? Is there a life after death? Answers to these questions have been a quest of humankind from the beginnings of history. Today we may be more technologically advanced, but are we more spiritually advanced than our ancestors?

Importance of Spirituality in Medicine Doctors have always been more than “human body mechanics,” and spirituality has always been an integral part of medical care. In ancient times, doctor and priest were one, and the same person cared for both body and soul. According to the recent Gallup poll, 94% of Americans believe in God or a Higher Power.1 In a similar vein, 79% of US family doctors reported a strong religious or spiritual orientation.2 Nearly two-thirds of people would like their doctors to talk to them about spirituality or pray with them.3-6 We find these statistics consistent with our own everyday patient encounters—nearly all of our patients appreciate it when we bring up spiritual issues. We find it helpful to imagine what it will be like as we lie on our dying beds. What will come to our minds as the most important things in our lives? We doubt it will be the money, property, or prestigious titles that we have accumulated. More likely, we will call to mind something related to love, family or eternity. No wonder, then, that spirituality is important to the practice of medicine.

Spirituality and Health Outcomes In the midst of rapid technological advancements—the widely publicized Genome Project, gene therapy, cell and

animal cloning, for example—has come an increased emphasis on the spiritual in medicine. We searched MEDLINE for published papers containing the keywords “spirituality” or “prayer.” Figure 1 shows the virtually exponential increase in the number of such papers over the past 30 years. In recent years, researchers have investigated the relationship between health and religious behavior or spirituality. McBride et al reported that patients who scored higher on ratings of spirituality had better overall health.7 Koenig et al reported that greater intrinsic religiosity shortened the time to remission for patients with major depression.8 Or maybe it’s the other way around. Thomas et al reported that critically ill patients had a greater sense of purpose in life than non-critically ill patients or healthy controls.9 Chronically ill or terminal patients have significantly higher levels of spiritual well-being.10,11 Two double-blind, randomized studies have found that intercessory prayer was correlated with fewer adverse events and better clinical outcomes for patients admitted to coronary care units.12,13

Limitations of Spirituality Studies Even studies of spirituality that are methodologically sound have limitations. They should be interpreted with caution and the conclusions not extrapolated beyond the study context.14 One difficulty in comparing studies is the different meanings assigned to “spirituality” by different people. It is a term that is hard to define precisely, so making direct comparison among studies is difficult.15 There are also differences between religious behavior and spirituality. Payne argues that intrinsic differences in religious beliefs may make it inappropriate to lump patients of different religion backgrounds together in a study.16 Not only is it difficult to define spirituality, it is difficult to measure and quantify it. Arbitrary scoring of measurement scales for spirituality, overall health, and health outcomes compounds the problem of interpreting these studies.17 For

The authors are with the Section on Hematology-Oncology, Department of Internal Medicine, at the Wake Forest University Comprehensive Cancer Center, Winston-Salem, NC 27157 They can be reached at (336) 716-5847 or by email at [email protected].

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example, how can you decide when patients with hyperten- more open to communicating with terminally ill patients and sion are healthier than those with depression, and vice versa? their families about death and dying.22 Today, many medical The problems of difficult-to-interpret results are exempli- schools incorporate religious and spiritual issues into their fied by several studies. Some show that sicker patients tend curriculums and residency programs.21,23,24 At Wake Forest to be more spiritual,9-11 and others show that more spiritual University School of Medicine, issues of spirituality and endpatients have better overall health or better response to of-life care are taught, together with medical ethics and legal therapy.7,8 Does spirituality improve health, or does bad medicine, in lectures and group tutorials given during the first health or clinical outcome lead to increased spirituality? The two years of school. answer is open to speculation. It may be that as patients get End-of-life care is a topic routinely incorporated into sicker, they become more spiritual. In any case, correlation continuing education programs like the annual meetings of should not be confused with causation. American College of Physicians and the American Society of The effects of prayer are also controversial.18,19 Is it Clinical Oncology. In this era of medical specialization, even possible to have a genuine “control” group? Someone, in doctors who feel too busy to provide emotional and spiritual some remote village, counseling themwho prays generously selves, can always for sick people all over designate qualified the world may, in professionals—pastheory, upset the detoral counselors, sosign of randomized cial workers, clinical trials of intercessory psychologists—who prayer. Another probcan offer guidance. lem relates to the notion of qualitative difference among differSpiritual Care: ent prayers by differPersonal ent persons. Are Sharing heartfelt prayers recited by spouses into According to differthe ears of patients ent religious tradiqualitatively more sigtions, life ends in one nificant than prayers of three “Rs”: recyof strangers in remote cling, reincarnation, areas? It seems almost or resurrection. impossible to control Atheists believe that these variables. life ends and then the Limitations do body’s components not imply that studies recycle. Buddhists Figure 1. Exponential growth of literature on “spirituality” and “prayer” of spirituality are unand adherents to necessary or irrelevant. Knowing the limitations helps us Eastern religions hold that after life ends the spirit is reincarinterpret the studies correctly and contextually, and lets us nated into new generations of life forms. Christians, Jews, apply the results more appropriately. It should be empha- and Muslims believe that life ends with the hope of eternal sized that the importance of spirituality in medical practice life. was established before there were any data suggesting correProviding spiritual support to dying patients can inspire lations to health outcome. Spiritual care is important because hope and help them deal with their impending death, within we care about our patients as whole persons. the framework of their own religious beliefs.25 Suffering ceases in some way at the moment it becomes meaningful.26 Some patients have obvious difficulties in relating their Spirituality and Medical Education suffering to their own beliefs. They become depressed and ask for help; we should address their spiritual needs as much Though important, only recently have the spiritual aspects of as we treat their medical problems. We can report from our patient care been taught in medical schools.20,21 Perhaps the personal experience that taking an active role in the spiritual practice of medicine is the best curriculum for learning about counseling of patients is very rewarding. In the process, we the importance of spirituality in people’s lives. According to also learn the inevitable lesson: “Be prepared because you, a recent study, doctors who had practiced for 20 years were like the patient, will eventually lie on a hospital bed.”


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Figure 2. From a headstone in a cemetery in Dallas, Texas.

What are the desirable outcomes of spiritual care? Prolonged survival? Fewer adverse events in the coronary care units? If one defines spirituality as closeness to God, then the outcomes probably transcend biological measurement. The desired outcomes are more likely to be qualitative ones like joy, tranquility, or inner peace despite the deterioration of the physical body (Figure 2). Ultimately, these transcendent states may help patients reach the final stage of acceptance of the inevitable,27 of “Thy will be done.” They may also help families to accept what is coming, and encourage mutual forgiveness within the family. One Sunday the preacher said, “Prayers seldom change reality. However, they almost always change our hearts.” This is the true value of prayer. It has the power to change our hearts if not our broken bodies. Acknowledgment. We are indebted to Pastor Van Lo, M Div, Department of Pastoral Counseling, Wake Forest University, for his review and advice on this manuscript.

References 1 Gallup Poll. Religion in America: December 1999. Princeton, NJ: The Gallup Organization, 1999. 2 Daaleman TP, Frey B. Spiritual and religious beliefs and practices of family physicians: a national survey. J Fam Pract 1999;48:98-104. 194


3 McNichol T. The new faith in medicine. USA Today. April 7, 1996:4. 4 Ellis MR, Vinson DC, Ewigman B. Addressing spiritual concerns of patients: family physicians’ attitudes and practices. J Fam Pract 1999; 48:105-9. 5 Ehman JW, Ott BB, Short TH, et al. Do patients want physicians to inquire about their spiritual or religious beliefs if they become gravely ill? Arch Intern Med. 1999;159:1803-6. 6 King DE, Bushwick B. Beliefs and attitudes of hospital inpatients about faith healing and prayer. J Fam Pract 1994;39:349-52. 7 McBride JL, Arthur G, Brooks R, Pilkington L. The relationship between a patient’s spirituality and health experiences. Fam Med 1998; 30:122-6. 8 Koenig HG, George LK, Peterson BL. Religiosity and remission of depression in medically ill older patients. Am J Psychiatry 1998;155:536-42. 9 Thomas JM Jr, Weiner EA. Psychological differences among groups of critically ill hospitalized patients, noncritically ill hospitalized patients, and well controls. J Consult Clin Psychol 1974;42:274-9. 10 Miller JF. Assessment of loneliness and spiritual well-being in chronically ill and healthy adults. J Prof Nurs 1985;1:79-85. 11 Reed PG. Spirituality and well-being in terminally ill hospitalized adults. Res Nurs Health 1987;10:335-44. 12 Byrd RC. Positive therapeutic effects of intercessory prayer in a coronary care unit population. South Med J 1988;81:826-9. 13 Harris WS, Gowda M, Kolb JW, et al. A randomized, controlled trial of the effects of remote, intercessory prayer on outcomes in patients admitted to the coronary care unit. Arch Intern Med 1999;159:2273-8. 14 Sloan RP, Bagiella E, Powell T. Religion, spirituality, and medicine. Lancet 1999;353:664-7. 15 Dyson J, Cobb M, Forman D. The meaning of spirituality: a literature review. J Adv Nurs 1997;26:1183-8. 16 Payne FE. Research on spirituality: dangerous and deceptive ground? J Fam Pract 1999;48:501-3. 17 Daaleman TP, Frey B. Association between spirituality and health hard to measure. Fam Med 1998;30:470-1. 18 Roush W. Research News. Science 1997;276:357-9. 19 Crowley TJ. Testing the power of prayer. Science1997;276:1631. 20 Gloth FM, III. Hospice: the most important thing you didn’t learn in medical school. Md Med J 1994;43:511-3. 21 Levin JS, Larson DB, Puchalski CM. Religion and spirituality in medicine: research and education. JAMA 1997;278:792-3. 22 Dickinson GE, Tournier RE, Still BJ. Twenty years beyond medical school: physicians’ attitudes toward death and terminally ill patients. Arch Intern Med 1999;159:1741-4. 23 Maugans TA. The SPIRITual history. Arch Fam Med 1996;5:11-6. 24 Silverman HD. Creating a spirituality curriculum for family practice residents. Altern Ther Health Med 1997;3:54-61. 25 Hamilton DG. Believing in patients’ beliefs: physician attunement to the spiritual dimension as a positive factor in patient healing and health. Am J Hospice Palliat Care 1998;15:276-9. 26 Frankl VE. Man’s Search for Meaning: An Introduction to Logotherapy. Boston, MA: Beacon Press, 1963. 27 Kubler-Ross E. On death and dying. New York: Macmillan and Co., 1969.

Spirituality—Cum Grano Salis: A Commentary The article by Drs. Keung and McQuellon in this issue of the Journal1 reminds us again that doctors should pay attention to the spiritual life of the patients they treat. Twenty-four hundred years ago, in ancient Greece, Plato staked out the territory pretty clearly when he said: I dare say that you have heard eminent physicians say to a patient who comes to them with bad eyes, that they cannot cure his eyes by themselves, but that if his eyes are to be cured, his head must be treated; and then again they say that to think of curing the head alone, and not the rest of the body also, is the height of folly. And arguing in this way they apply their methods to the whole body, and try to treat and heal the whole and the part together. . . . . . I learned [these lessons] when serving with the army from one of the physicians of the Thracian king Zamolxis, who . . . told me that. . . ‘as you ought not to attempt to cure the eyes without the head, or the head without the body, so neither ought you to attempt to cure the body without the soul; and this,’ he said, ‘is the reason why the cure of many diseases is unknown to the physicians of Greece, because they are ignorant of the whole, which ought to be studied also; for the part can never be well unless the whole is well.’ For all good and evil, whether in the body or in human nature, originates, as he declared, in the soul, and overflows from thence, as if from the head into the eyes. And therefore if the head and body are to be well, you must begin by curing the soul; that is the first thing. And the cure . . . has to be effected by the use of certain charms, and these charms are fair words; and by them temperance is implanted in the soul, and where temperance is, there health is speedily imparted, not only to the head, but to the whole body. And he who taught me the cure and the charm at the same time added a special direction: ‘Let no one,’ he said, ‘persuade you to cure the head, until he has first given you his soul to be cured by the charm. For this,’ he said, ‘is the great error of our day in the treatment of the human body, that physicians separate the soul from the body.’2

It seems to me that Plato and Keung and McQuellon make the same argument: that true healing requires attention to the spiritual facets of patients’ lives, and that doctors ignore the importance of the spiritual at their great peril (although I am not sure exactly what Plato was talking about when he used the word that Professor Jowett translates for us as “soul”). In the arguments they set forth, Plato and Keung and McQuellon clearly take the side of the angels. I suppose it is true that patients appreciate and respond when doctors pay attention to their spiritual lives, and I think they feel a sense of bond when they assume (or presume) that their doctors share spiritual and religious creeds with them¾but does healing depend on this? I know there is testimony about the importance of the spiritual in medical practice, but we have been talking about this for two and a half millennia or more, and where is the evidence that it makes a difference? Science might help us here, but designing appropriate studies is enormously difficult (what is the appropriate placebo control for attending to spirituality? ignoring or belittling spirituality? being oblivious to the spiritual dimensions of persons’ lives?). Some of the studies that have been tried seem to me ludicrous— for example, randomized trials of anonymous, intercessory prayer. The underlying assumption seems to be that God wants to talk to humans, and used to know Hebrew, but has forgotten and nowadays can only speak mathematical statistics. Harry Houdini couldn’t talk to us from the other side of the grave, and the telephone in Mary Baker Eddy’s tomb has not rung, but t-tests will tell us whether God is listening? Please! Hubris, the recurring sin of humankind, continues, supported by wishful thinking and money from foundations and governments. If I am skeptical about whether attention to the spiritual is really different from attention to any other of the many personal aspects of peoples’ lives, I do not want to suggest that failure to attend to the personal won’t make a difference. To ignore patients’ personal lives is to be—or at least seem to be—callous and indifferent, to not care. And if, as Francis Weld Peabody said, the “secret of the care of the patient is in caring for the patient,”3 then even seeming to not care will undermine our positions as doctors. I don’t want to do that. So I will listen carefully to the arguments of Plato and Keung and McQuellon and their successors, and hope that another two centuries of centuries will bring the lens of science to sharp focus on this problem. —Francis A. Neelon, MD 1. Keung Y-K , McQuellon R. When medical meets spiritual. N C Med J 2001;62. 2. Jowett B. Charmides. In The dialogues of Plato, vol 1. Oxford University Press. London, New York, 1924. 3. Peabody FW. The care of the patient. JAMA 1927;88:877-82.


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