Correspondence
Medicine and Religion
N Engl J Med 2000; 343:1339-1342November 2, 2000
- Article
To the Editor:
I am concerned that Sloan and colleagues (June 22 issue)1 justify separating religion and spirituality from medical practice by holding up and condemning an extreme position, which is that doctors should prescribe religious activities and counsel patients in spiritual matters. I agree that physicians have no business doing either of the above, but they could take a spiritual history as part of their evaluation of seriously ill patients.
A task force of the American College of Physicians has suggested four simple questions.2 If a patient indicated that religion was not important to his or her medical care, the physician would not explore further but instead would ask how the person was coping with the illness. If the patient reported using religious beliefs to help cope with illness, then the physician might decide to support those beliefs. Supporting them does not mean recommending or prescribing; it means acknowledging, respecting, and perhaps encouraging the beliefs that the patient finds helpful in relieving suffering. Some religious beliefs that run counter to appropriate medical care may need further exploration with the patient, the patient's minister, or both.
2 ReferencesHarold G. Koenig, M.D.
Duke University Medical Center, Durham, NC 277101
Sloan RP ,Bagiella E ,VandeCreek L , et al. Should physicians prescribe religious activities? N Engl J Med 2000;342:1913-1916
Full Text | Web of Science | Medline2
Lo B ,Quill T ,Tulsky J . Discussing palliative care with patients. Ann Intern Med 1999;130:744-749
Web of Science | Medline
To the Editor:
In 16 years of family practice, my experience could hardly be more in conflict with the conclusions of Sloan et al. Although I do not routinely inquire about patients' religious or spiritual lives, it is not unusual for me to do so. Most frequently, I ask such a question when patients are suffering from progressive, incurable, or fatal illness. It also seems relevant to inquire when patients are struggling with mental anguish or addiction.
It is my practice to ask patients whether spirituality or religion is important in their lives. I then listen, respectfully, to their experience. Some patients report little engagement with these matters, and we go on to other subjects. Many patients talk of the central part God plays in their lives and in their experience of illness. Some describe the comfort and support they obtain from religious and spiritual sources, and I validate this response and encourage them. Some say they have lost touch with religion and spirituality and wish to reconnect with them, and we discuss that. We then go on to the issues of diagnosis and treatment.
I have had many hundreds of such conversations, and not a single patient has responded negatively. The information informs my approach to patients in discussing their illness and their medical choices, sometimes in important ways. I come to know my patients in a deeper way, and they feel seen and heard in ways that matter to them. This approach helps me treat them, and heal them, particularly when they are facing incurable illness or death.
David E. Nicklin, M.D.
University of Pennsylvania, Philadelphia, PA 19104To the Editor:
As an attorney deeply involved in health care and medical-malpractice issues, I read the article by Sloan et al. with some skepticism. Aside from the dearth of empirical evidence of a relation between health and religion, two things are clear. First, ill persons are more vulnerable than the general population to proselytization. Second, the likelihood that the patient and the physician will have similar religious beliefs is becoming smaller as subspecialization and managed care dictate the choice of a physician.
In areas in which alternative or novel approaches to care are offered, a thorough process of informed consent is traditionally required, with the opportunity cost of such treatment spelled out. Prayer as an adjunct to appropriate treatment might seem innocuous at first blush but could tacitly suggest to a patient that one approach to medical treatment held some spiritual or even more concrete advantage.
Experience tells us that the reference to religion in recommending medical care could be abused intentionally or inadvertently and could create a new source of liability in a field already besieged by novel theories.
Andrew S. Kaufman, J.D.
Kaufman, Borgeest & Ryan, New York, NY 10017To the Editor:
I think the chaplains are creating a tempest in a teapot. Their article does not present any evidence of a problem that has been created that needs to be mitigated. Is there evidence that physicians are doing harm to patients? Is there evidence that patients feel physicians are trivializing religion? Is there evidence that physicians are practicing religion without the proper credentials and doing harm to patients? The evidence cited in the article simply underlines that many patients would like physicians to be sensitive to religion and spirituality.
It sounds as if some chaplains have created a map of a territory that does not actually exist and are responding to a fear that is unfounded. Relax, chaplains, your boundaries are safe.
Roger W. Hite, Ph.D.
Dominican Santa Cruz Hospital, Santa Cruz, CA 95065To the Editor:
If health is viewed as physical, psychological, social, spiritual, and moral well-being, then it is simply not true that religion and medicine “exist in different domains,” as Sloan et al. assert. Human experience and understanding cannot be compartmentalized in this fashion.
Respectful curiosity has long been a hallmark of good physicians. We routinely ask patients about private matters in an effort to screen for depression, domestic violence, and alcoholism. What do we then do with this information? Usually, we refer the patient to a professional with appropriate training and skills. A similar approach to questions about spiritual or religious resources or distress may be very appropriate in many circumstances.1,2 As always, the patient remains free to decline referrals or refrain from answering questions.
2 ReferencesJacqueline R. Cameron, M.D.
Northwestern University Medical School, Chicago, IL 606111
Holland J . Update: NCCN practice guidelines for the management of psychosocial distress. Oncology 1999;13:459-507
Web of Science2
Fitchett G . Screening for spiritual risk. Chaplaincy Today 1999;15:2-12
To the Editor:
As both a physician and an Episcopal priest, I do not find the substance of the arguments presented by Sloan et al. persuasive. What puzzles me is the authors' resistance to physicians' interest in the spiritual aspects of medical illness. Their apprehension clearly stems from something deeper than a simple battle over turf. I suspect the root may be an overly zealous separation between religion and medicine.
The authors state that religion and medicine “exist in different domains and are qualitatively different.” I agree, but I would add that medicine is not pure science, and religion is not pure theology. Medicine and religion apply science and theology, respectively, in the context of human lives, and in the process, their domains intersect. The artful practice of medicine reaches beyond pure science to guide patients as they weave the experience of illness into the fabric of their lives. Insofar as religion is one of the most prevalent and powerful ways in which people find meaning and value in experience, including illness, we physicians would be foolish to ignore the diverse resources for faith that are available to (and being used by) our patients. Similarly, it would seem that hospital chaplains would welcome their medical colleagues' acknowledgment of the spiritual aspects of illness and healing.
Daniel E. Hall, M.D., M.Div.
University of Pittsburgh Medical Center, Pittsburgh, PA 15213To the Editor:
Several aspects of the Sounding Board article by Sloan et al. are problematic. The title — “Should Physicians Prescribe Religious Activities?” — contains three assumptions that frame the topic in a highly biased and restricted fashion. First, the title refers only to physicians, disregarding the multidisciplinary nature of health care. Second, the focus on prescribing evokes an authoritarian, hierarchical, expert-directed model of care that does not work well for diabetes, let alone spiritual distress. Third, focusing attention on “religious activities” specifically, rather than on spiritual experience in general, forces differences of doctrine to the foreground and obscures the possibility of a more appropriate and respectful generic approach.
There are also muddled arguments and contradictions in the article. Sloan et al. imply that because religion is “personal and private,” it is not appropriate for medical discourse. But what is more personal and private than the experience of illness? Moreover, the authors contradict their own point when they later recommend referrals for pastoral care. How does a primary care clinician recognize the need for such a referral without exploring the patient's spiritual experience? The authors oppose conversations with patients about religion because such conversations are complex and because physicians are not suitably trained to engage in them, yet the authors mention the growing number of medical schools that offer courses in this area. They say that clinical trials are needed to justify treatment recommendations and then later decry the instrumental application of religious activities. Their comment about diversity, which combines Islam and Judaism while keeping Christian denominations distinct, is an embarrassment.
Anthony L. Suchman, M.D.
42 Audubon St., Rochester, NY 14610To the Editor:
Sloan et al. point out that studies show that only a minority of patients would be interested in having a spiritual component of their medical visit, and most of these studies have been performed in family-practice settings. However, we found that in the setting of general internal medicine, more than 70 percent of patients desired prayer with their physician. Our study of 600 patients was equally divided among three hospital settings (a university hospital, a Veterans Affairs hospital, and a county hospital) and was also equally divided between outpatients and inpatients. Most of the patients who wanted prayer with a physician wanted it at the current clinic visit or during hospitalization (the remainder wished for prayer at a future visit).1
In addition, we were able to address another of the authors' concerns — the difficulty of identifying patients who want to discuss spiritual issues. Our study was specifically designed to help physicians easily identify which patients would desire prayer with them. Of the many variables assessed, only a few were found on multivariate analysis to be statistically significant predictors of a patient's desire for addressing this topic — namely, sex and some variables associated with spirituality. The setting (inpatient or outpatient), the type of hospital, the patient's age, social support, and the patient's quality of life, state of health, functional status, and medical prognosis were not significant predictors. Women were more interested in prayer than men (83 percent vs. 63 percent, P=0.02). The most significant spirituality-related variable (P=0.003) was the response, on a scale from 1 to 9, to a single item, “Indicate how important spirituality is to you.”2
2 ReferencesDaniel Castro, M.D.
Jerry L. Pettis Memorial Veterans Affairs Medical Center, Loma Linda, CA 92357Lawrence K. Loo, M.D.
Riverside County Regional Medical Center, Riverside, CA 92555Debra L. Stottlemyer, M.D.
Loma Linda University, Loma Linda, CA 923501
Castro D ,Loo LK ,Skoretz LE ,Stottlemyer DL ,John S-J ,Buenjemia J . Patients who desire prayer: can physicians identify them? J Gen Intern Med 2000;15:Suppl 1:57-57
Web of Science2
Gorsuch RL ,McFarland SG . Single vs. multiple-item scales for measuring religious values. J Scientific Study Religion 1972;11:53-64
CrossRef | Web of Science
Author/Editor Response
The authors reply:
To the Editor: Our Sounding Board article was prompted by published reports and articles in the popular press suggesting that physicians prescribe religious activities as adjunctive medical treatments.
Both Koenig and Suchman assert that our approach was biased. Our focus on physicians does not make the issues we raise any less relevant for other health care professionals. Linking religious activity to medical outcomes is inappropriate because of the dearth of solid evidence and substantial ethical issues.
Contrary to Suchman's assertion of bias in our view of the physician–patient relationship, health care remains “expert-directed.” This is why patients with heart disease see physicians and not accountants. When seeking recommendations from experts, seriously ill patients are likely to be fearful and correspondingly vulnerable to suggestions to engage in religious activities, as Kaufman points out.
Koenig recommends that physicians take a spiritual history to determine how a patient is coping with an illness. If bias arises here, it is in the emphasis on religious activity in coping. Patients cope with chronic illness in many ways. Religion-based coping is important but not unique. Why not simply ask about coping directly? Patients who mention religious issues can be referred to chaplains or local clergy.
Nicklin, Cameron, and Hall all argue that the content of the physician–patient relationship cannot be compartmentalized to exclude religion and spirituality. Although this may be true, it does not mean that physicians should involve themselves in discussions of such freighted matters. Spiritual issues and conflict between religious beliefs and recommended treatments are complex and time-consuming matters, and they require the attention of a professional caregiver.1
The letter from Castro et al. permits us to make our point. In reporting that 70 percent of the patients in their study wanted their physicians to pray with or for them, do Castro et al. imply that the physicians were ready to do so, possessed sufficient information about the patients to do so knowingly, and were sufficiently religious or spiritual to pray sincerely? Are they concerned about the great and increasing likelihood that physician and patient may be from different religious traditions? Are they arguing that these considerations are irrelevant?
Finally, both Hite and Hall believe that the chaplains seek to protect their professional territory. Who can better address these issues than professionals with training and clinical experience in the area of religion and spirituality in the lives of patients?
1 ReferencesRichard P. Sloan, Ph.D.
Columbia University College of Physicians and Surgeons, New York, NY 10032Larry VandeCreek, D.Min.
Margot Hover, D.Min.
HealthCare Chaplaincy, New York, NY 100221
Holland JC . Update: NCCN practice guidelines for the management of psychosocial distress. Oncology 1999;13:459-507
Web of Science
- Citing Articles (7)
Citing Articles
1
Shelley Wiechman Askay, Gina Magyar-Russell. (2009) Post-traumatic growth and spirituality in burn recovery. International Review of Psychiatry 21:6, 570-579
CrossRef2
Raphael M. Bonelli. (2007) Ist der Faktor "Religiosität" in der modernen Psychiatrie relevant?. Psychiatrie und Psychotherapie 3:1, 14-22
CrossRef3
Gregory P. Lekovic, Timothy R. Harrington. (2007) LITIGATION OF MISSED CERVICAL SPINE INJURIES IN PATIENTS PRESENTING WITH BLUNT TRAUMATIC INJURY. Neurosurgery 60:3, 516???523
CrossRef4
Brett D. Arnoldo, John L. Hunt, Agnes Burris, Linda Wilkerson, Gary F. Purdue. (2006) Adult Burn Patients: The Role of Religion in Recovery—Should We Be Doing More?. Journal of Burn Care & Research 27:6, 923-924
CrossRef5
Wanda K. Mohr. (2006) Spiritual Issues in Psychiatric Care. Perspectives In Psychiatric Care 42:3, 174-183
CrossRef6
Norbert Grulke, Harald Bailer, Gerd Blaser, Michael Geyer, Elmar Brähler, Cornelia Albani. (2003) Measuring religious attitudes: reliability and validity of the German version of the Systems of Belief Inventory (SBI-15R-D) in a representative sample. Mental Health, Religion & Culture 6:3, 203-213
CrossRef7
Anne Hendren Coulter. (2003) Is Prayer a Placebo?. Alternative and Complementary Therapies 9:2, 78-81
CrossRef
