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When Religion and Medicine Embraceby Harold G. Koenig, M.D.
Religion and medicine are beginning to come together again. You and I know the relevancy of God in the healing process, but in our society at large, this is still very controversial. Only about one in twenty physicians nationwide about 5 percent regularly addresses the spiritual issues of patients. (In the South, it's closer to 9 percent.) The dominant majority of health professionals are not addressing spiritual issues, don't really understand the relevance of spiritual issues, and don't really know what to do even if they know these issues are relevant. I believe that statistical evidence is telling us that the approach among health professionals must change. It's time for religious faith and medical practice to shake hands and join forces once again. Once again? That's right. The first large hospital to care for the sick was built by the Bishop of Caesarea of the Eastern Orthodox Church in Turkey during the fourth century. During the next twelve hundred years, the Christian church built hospitals throughout Western Europe, and largely staffed those hospitals. The first people who cared for the sick in these hospitals were from religious orders, primarily the religious sisters of the Catholic Church. The doctors were usually monks or priests. This continued throughout the Middle Ages, with the training done in church sponsored universities, which gave out licenses for doctors to practice medicine. The Catholic Church slowly began to loose its control over the Western World with the Protestant Reformation and the Enlightenment. With the spectacular scientific advances of the late 1800s, religion and medicine became nearly completely separated. In fact, many of the scientific disciplines began to define themselves as not being religious disciplines, thus defining themselves in contrast to religion. So a wide barrier between science and religion was erected and endures to this day. There were, of course, trends against this broad sweep of history. For instance, the first physicians in the American colonies were also ministers. (Many practiced medicine to supplement their meager incomes.) In addition, the Quakers influenced early psychiatric care in the United States with what was called "moral treatment" of the mentally ill. Instead of confining them in dungeons or prisons and treating them with enemas, cathartics, bloodletting, and ice water baths, they were brought into a homelike atmosphere, given some work to do, and treated with respect. Out of the joint efforts of science and religion grew the first psychiatric hospital (Friends Asylum in Philadelphia), the American Psychiatric Association, and the American journal of Psychiatry. The early religious roots of psychiatry have been lost, however, largely due to the strong influence of Sigmund Freud. Many psychologists and psychiatrists today are resistant to the notion that religion is anything but neurotic. That's not to say that religious people are always balanced in their approach to medicine. Religion can interfere with medical care; it is sometimes used instead of medical care, as people believe they have been healed by God through prayer and want to demonstrate their faith by stopping their medications. Religion can be used to justify noncompliance. It's difficult for most modern day Christians to find the proper balance between faith and medicine. But today in North America people are seeking a balanced reconnection- whether through orthodox Christianity, new age spirituality, or other religions. People are discovering that there is some connection between faith and medicine, and they are trying to integrate the two, at both the professional and lay levels. We are finding that there is an intricate connection between our minds, our emotions, and our physiology. A simple example is that when we are under stress, our heart rate increases, our blood pressure goes up, and our immune system changes. We are rediscovering that human beings are created in such a way that our faith and our emotions can influence our physiology and our ability to recover from illness. If this is the case, we ought to consider religious faith relevant in our healing practices. One patient profoundly impacted a secular professor of medicine at Harvard who happened to be the editor of the "Clinical Crossroads" section of JAMA (the Journal of the American Medical Association). She published a substantial article about the patient in that section.1 This patient was an eighty three year old woman with multiple serious medical problems: spinal stenosis, advanced arthritis, peripheral neuropathy, plus diabetes with all its associated long term consequences. She had chronic, progressive, unrelenting pain. Traditional medical treatments and even narcotic pain relievers were ineffective, as were alternative medical treatments such as acupuncture and massage. She had limited material resources; she lived alone. Yet she was doing well psychologically despite all of these difficulties. She was positive, hopeful, and optimistic. The physician was amazed at how positive she was about her situation. She functioned independently, with no assistance whatsoever from health aides or family. Not only that, she even helped other people who were sick. She had people take her to the hospital in her wheelchair, where she wheeled around and visited and prayed with the patients. How did she do it? She said religion. As people of faith, we are not surprised that her faith could sustain her in this way, but when this was presented at Harvard medical grand rounds, the doctors seemed surprised. She said, "I walk and I talk with God. This is the basis for my health: prayer and faith in my Lord, my guide and protector." She was quoted in the JAMA article as she laid out the gospel and her faith commitment. Actually, this woman is amazing but is not all that uncommon. No matter what the age, people of faith who are ill rely on their faith to give them strength and help them cope. And it does. There's something about loosing control of one's own life, as people do when they become chronically ill, that often pushes them towards religion or stretches their faith. About a week after September 11, 2001, the New England Journal of Medicine conducted a survey in which they asked people how they were coping. Besides talking with others, they were coping by turning to religious faith. In fact, nine out of ten Americans turned to religion. I think this is powerful evidence for health practitioners as well as clergy: we need to be aware of and attuned to the coping behaviors that the vast majority of patients are using in the face of their personal crises. At the Duke University Center for the Study of Religion/Spirituality and Health, in addition to our own research, we have reviewed and analyzed hundreds of studies that have, in various ways, looked at the relationship between faith, prayer, spirituality and health. Some brief observations based on the work we have done are mentioned below. Fifteen out of sixteen studies which looked at purpose and meaning in life and measured some kind of religious variable, show that religious people have greater purpose and meaning in life, particularly when they become sick. It's not that our health care system doesn't know that there's a strong connection between health and faith, but this fact hasn't been widely disseminated yet. Patients are relying heavily on their faith to make meaning of their illness and to help them make their medical decisions. Why has this knowledge been largely ignored? Part of it has to do with the lack of knowledge about the research that's actually out there. A very large number of studies have shown statistically significant correlations between a faith factor and a positive health outcome. Some 80 percent of relevant studies show greater well-being, hope, and optimism among those who rely on their faith. All of these studies and others 1,200 separate studies in all with some 2,000 references are documented in the back of my book entitled Handbook of Religion and Health (see sidebar). The studies repeatedly show that the more deeply religious individuals are, the more likely they are to cope and adapt to their medical problems, compared to people who are less deeply religious. In those who are chronically ill and aren't getting better, this effect becomes magnified. In addition, in a community of elderly, wellbeing seems to go up with increasing levels of intrinsic religiosity. This effect is quantitative; the more intrinsic the religiosity, the greater the sense of wellbeing. My colleagues and I have developed a medical model to understand and explain how religion influences physical health. The model is not trying to prove that God or the supernatural exists; it's only trying to demonstrate what effect a deep religious faith one that includes prayer, being part of a religious community, and volunteering within that religious setting has on a person's mental and physical health. The model proposes that faith does influence mental health, affect social support, and influence health behaviors. Whether you believe that God exists or not, this makes scientific sense. You would expect stress hormones to be lower, the immune system to work a little better, the autonomic neurosystem not to be quite as hyper reactive. Because social support is greater, diseases are often detected a little sooner and treatment compliance is better because people are part of a community that checks up on one another. So you'd expect illnesses to be less common among those who are more religious. This is a logical, rational model that could and should be integrated within all of our health care system. Research has indeed shown that religious people do, in general, tend to be healthier and live longer. Consider the fact that, according to five out of five studies, religious people appear to have better immune functioning. One study took a group of college students and randomly divided the group in half One group was shown a film of World War II, while the other watched a film about Mother Theresa caring for the sick in India. Afterwards, researchers measured the IGA levels in their saliva, an indicator of immune function. Significantly higher IGA levels were measured in those who watched Mother Theresa. Another study had to do with Interleukin 6, which the body's lymphocytes use to communicate with each other. As people grow older, their immune systems tend to experience greater levels of Interleukin 6, as they have to work harder to communicate. (People with AIDS, HIV, and lymphoma also have increased levels of Interleukin 6 in their blood-streams.) Lower levels of Interleukin 6 may suggest a healthier, younger-appearing immune system. Frequent church goers in the study had significantly lower Interleukin 6 levels in their blood-streams. A third study from the University of Iowa found the same connection between greater religious or spiritual coping and lower levels of Interleukin 6. The fourth study looked at "religious expression" among patients with advanced metastatic breast cancer. It found that those who had greater religious expression had higher numbers of T helper cells, greater total lymphocytes, and greater natural killer cell activity. The fifth study looked at long term survivors with AIDS. They found that those who are more religious are living longer. The lower cortisol levels detected were apparently due to altruistic activities of those religious patients with AIDS who were reaching out encouraging, emotionally supporting, and possibly spiritually supporting others who had AIDS. A big study is now underway at Johns Hopkins to look at prayer for healing among African Americans with breast cancer. Each patient chooses eight other women in her church to meet weekly to pray for her using a "centering prayer" approach (similar to meditation), but perhaps also by laying hands on her, giving testimonies, dance, praise, and so on. In other words, they hold full scale prayer meetings in their own tradition, in addition to following the centering prayer study protocol. Hopkins immunologists are drawing blood from the patients every month for six months and comparing them to a control group of women who are just receiving education about breast cancer. This is the first NIH funded study to examine prayer in this manner. Sometimes, of course, people experience struggles with their faith. In the face of a medical crisis, they ask, "God, why me?" "Why doesn't God heal me?" Such questions are normal and natural. Most people move through this bereavement phase as they adapt to their loss of health. Often they get angry, though most resolve their anger and learn to cope. Some people get stuck there, however, and continue to ask, 'Why me, God? Are you punishing me? Do you not love me? Have you deserted me?' When they get stuck in these persistent thoughts, they experience significantly worse health outcomes. We health professionals have to detect those with negative thoughts and significant spiritual struggles because ongoing spiritual struggle has been shown to predict greater mortality. Addressing spiritual needs as medical professionals can be tricky, however. We're called as Christians to share our faith with people. We know from personal experience that when people turn their lives over to the Lord, most of them get healthier physically and emotionally. But in a secular setting, health professionals can't try to convert their patients, who are often vulnerable and dependent on them. I consider it unethical and outside the role of the physician. You cannot prescribe conversion to Christ as part of treatment. But you can take a spiritual history and get a dialogue going with your patients, identifying their spiritual needs as the patient understands them and meeting those needs as the patient directs. It is essential that such activity be patient centered, not doctor-centered. The article I wrote in JAMA recommends that every physician be willing to take a spiritual history, not on every patient but according to a set of guidelines. You might ask if religion or spirituality provides comfort or stress, for example, in order to help find what role religion plays in a patient's medical illness. Such questions can lead to making a referral to a hospital chaplain or local clergyperson if needed. There are many practical reasons to ask about a patient's religious beliefs. In taking a spiritual history, you might discover that the patient has beliefs that conflict with the medical care you want to prescribe. For instance, does the patient prefer prayer over medical treatment? You need to know that in order to provide good medical care. In a study in Pennsylvania, two thirds of patients indicated that their religious beliefs influence their medical decision making when they become seriously or terminally ill. Do they want feeding tubes or a "Do Not Resuscitate" order? If you can dialogue in a professional manner with your patients about their religious beliefs, they're less likely to get defensive. Sometimes you might be able to meet some of your patients' spiritual needs, and even pray with them although this must be done with great sensitivity and directly follow the wishes of the patient. Prayer can be the most powerful psychosocial intervention that you'll ever do in your entire life and career. Praying for the patient can be tremendously moving for both the patient and the physician. It can also get you sued if you're not careful! Because of a recent case, there is now precedent within the legal system for patients and their families winning suits against practitioners who pray with patients although if you do it with sensitivity based on your spiritual history of the patient, it is extremely unlikely that you would ever get sued for it. I believe that we as Christian health professionals are living during an incredible time in history. The potential of health care and longevity is vast. As we are learning how to prolong life through the results of stem cell and other research, the percentage of older adults in our populations around the world will continue to grow. That means that the medical and spiritual needs among our aging population will continue to grow. We need to be prepared to help our patients live not only longer but emotionally and spiritually happier and healthier lives. At the same time, Medicare is cutting reimbursement rates, and 20 percent of physicians nationwide are no longer accepting Medicare patients. The Medicare budget this year was $230 to $240 billion. The Health Care Financing Administration projects that by 2011 Medicare will rise, despite all the cost cutting efforts, to $450 billion. No one will even guess at the cost of Medicare beyond 2011. What does this mean in terms of health care? If we continue on this trajectory, only the sickest patients are going to get into the hospital, and the length of a hospital stay will get shorter. This will gradually escalate until the acute care hospitals will start to look like intensive care units. Only the sickest patients will come into an acute care hospital, to be rapidly sent off to a nursing home. Nursing homes will then start to resemble acute care hospitals, and the rest of medical care will be forced into the community. That means that people won't be able to get chronically ill loved ones into nursing homes, which means they'll have to care for them at home. People born between 1945 and 1970 are going to end up as the elderly in this situation, cared for by their children, who are also trying to hold onto jobs and raise their children. What a stressful situation for all! This brings me full circle. Remember what a vital role the church played for centuries in providing care for the sick? Many of the sick will once again end up in the laps of their religious communities. Pastors and willing church members will have to care for both aging congregants and young congregants trying to care for their aging relatives. One possible solution is for the health care system to start now to link together with religious communities. This would typically happen through a parish nurse, who can communicate with the outpatient clinic, acute care hospital, nursing home, and family members. The nurse can follow people's medical situations as well as explain what went on in the acute setting, and what needs to be done at home. This type of networking can also be done by volunteers from the religious community. We need volunteers mobilizing people healthy elderly people volunteering their time to provide care for the sick and not so healthy elderly people also caring for others, Remember the eighty three year old woman who baffled the medical community? Even the sick can do things; in fact, it will give more meaning to their lives. Have them get on the telephone and call people. Have them pray for their health providers, for the congregation, for individuals. I see volunteerism that links health care and faith as an exciting solution to the pending medical crisis. Unless this happens, we're going to be in trouble. But volunteerism doesn't come easy these days. Despite how many people say they want to do volunteer work, the volunteerism rate is fairly low. As the retirement age is dropping and the retired population is living longer, volunteerism has actually decreased in the last five years. Yet we know that when people are caring for others, it seems to make a difference physiologically and keeps them healthier. Volunteering to care for others should keep the healthy healthy and help the sick get the services they need. As I wrote in The Healing Connection (p. 175): "Our greatest gift to [those who are emotionally ill and physically distressed] may be to give them opportunities to become more active in our religious communities and in this way enable them to give out happiness and kindness to others." It's time for religion and medical care to again joins forces to improve people's health and longevity. We know that religious beliefs often play an important role for patients facing medical crises and chronic illness. We who know this crucial truth need to spread the word, become familiar with the studies undergirding it, and encourage open dialogue on the topic. Our lives, and the future of health care, depend on it. Harold G. Koenig, M.D., MHSc, is Associate Professor of Psychiatry and Associate Professor of Medicine at Duke University Center. He is Director and founder of the Center for the Study of Religion/Spirituality and Health at Duke. His website is: www.dukespiritualityandhealth.org. To find out more about getting a two year biostatistics degree from Duke to pursue a career in research such as that contained in this article, contact Dr. Koenig at KoenigOgeri.duke.edu. This article is based on a plenary address given May 17, 2002 at the CCHF annual conference at Eastern University. Other Resources Handbook of Religion and Health (Oxford University press, 2001) The Psychology of Religion & Coping (Guildford, 1997) |
