Note:
This is an academic article but, nevertheless, makes a strong
statement about the relationship between faith and health.
ehavioral Medicine Program, Columbia-Presbyterian
Medical Center (R P Sloan PhD, E Bagiella PhD) and Department
of Psychiatry, Columbia University (R P Sloan, T Powell MD);
New York State Psychiatric Institute (R P Sloan); Division of
Biostatistics, School of Public Health, Columbia University (E
Bagiella); and Center for the Study of Society and Medicine,
Columbia University (T Powell), New York NY 10032, USA
Religion and science share a complex history
as well as a complex present. At various times worldwide, medical
and spiritual care was dispensed by the same person. At other
times, passionate (even violent) conflicts characterized the association
between religion and medicine and science. As interest in alternative
and complementary medicine has grown, the notion of linking religious
and medical interventions has become widely popular, especially
in the USA. For many people, religious and spiritual activities
provide comfort in the face of illness. However, as US medical
schools increasingly offer courses in religion and spirituality[1]
and as reports continue to indicate interest in this subject among
both physicians and the general public, it is essential to examine
how, if at all, medicine should address these issues. Here, in
a comprehensive, though not systematic, review of the empirical
evidence and ethical issues we make an initial attempt at such
an examination.
Interest in connecting religion and
medicine
In a recent poll of 1000 US adults, 79% of the
respondents believed that spiritual faith can help people recover
from disease, and 63% believed that physicians should talk to
patients about spiritual faith.[2] Recent articles in such US
national newspapers as the Atlanta Constitution, Washington Post,
Chicago Tribune, and USA Today report that religion can be good
for your health. A new magazine, Spirituality and Health, edited
by the former editor of Harvard Business Review, has begun publication.
Eisenberg and colleagues, in a widely cited article on unconventional
therapies, noted that 25% of all respondents reported using prayer
as medical therapy.[3] King and Bushwick[4] reported that 48%
of hospital inpatients wanted their physicians to pray with them.[4]
Within the medical community, there is also
considerable interest. Meetings sponsored by the US National Institute
of Aging, the National Center for Medical Rehabilitation Research,[5]
and the Mind/Body Medical Institute, Beth Israel Deaconess Hospital,
Boston, have drawn large, enthusiastic audiences. Nearly 30 US
medical schools include in their curricula courses on religion,
spirituality, and health.[1] Of 296 physicians surveyed during
the October, 1996, meeting of the American Academy of Family Physicians,
99% were convinced that religious beliefs can heal, and 75% believed
that prayers of others could promote a patient's recovery. Benson
writes that faith in God has a health-promoting effect.[6] Larson
and Matthews argue for spiritual and religious interventions in
medical practice, hope that the "wall of separation"
between medicine and religion will be torn down,[7] and assert
that "the medicine of the future is going to be prayer and
Prozac" (ref 8, p 85). In an American Medical Association
publication, Matthews and colleagues recommend that clinicians
ask "what can I do to support your faith or religious commitment?"
to patients who respond favorably to questions about whether religion
or faith are "helpful in handling your illness'.[9]
Empirical evidence
In many studies, religion, as a putative antecedent
to health outcomes, has been measured in several ways eg,
assessment of religious behaviors, such as frequency of church
attendance or prayer; dimensions of religious experience, such
as the comfort it may provide; and health differences as a function
of differences in religious denomination or degree of religious
orthodoxy.
In addition, health outcomes vary considerably
eg, physical disease outcomes, mental health outcomes, and
health behaviors. Here, we consider methodological issues that
pertain to studies of physical disease outcomes.
Control for confounding variables and other
covariates
Confounders such as behavioral and genetic differences
and stratification variables such as age, sex, education, ethnicity,
socioeconomic status, and health status may have an important
role in the association between religion and health. Failure to
control for these factors can lead to a biased estimation of this
association. Multivariate methods allow estimation of the magnitude
of the association between religious variables and health outcomes
while controlling for the effects of other variables. However,
use of these methods requires complete presentation of the results--at
least the coefficients and corresponding confidence intervals
for all the variables in the statistical model. Reports that fail
to do this are incomplete and may be misleading.
Attempts to assess the effect of degree of religiousness
on health outcomes show this. Increased religious devotion, assessed
as service as a Roman Catholic priest,[10] nun,[11] Morman priest,[12]
, or Trappist or Benedictine monk,[13] is associated with reductions
in morbidity and mortality. These cases, however, were selected
for study precisely because they are inclined to stricter adherence
to codes of conduct that proscribe behaviors associated with risk
(eg, smoking, alcohol consumption, sexual activity, psychosocial
stress, and in some cases, consumption of meat).
In a series of studies from Israel,[14-16] religiousness,
measured as religious orthodoxy, was also shown to confer health
benefits. However, one of these[14] was a case-control study,
the deficiencies of which are widely known. In another,[15] a
multivariate model that predicted mortality from coronary heart
disease included standard risk factors but omitted religion, and
no information on risk-ratio or confidence intervals or even level
of statistical significance was provided. Finally, in a study
matching secular and religious Kibbutzim according to location,
use of the same regional hospital, and members older than 40 years,
all-cause mortality was significantly greater among members of
the secular Kibbutzim. However, the strategy of matching ensures
equivalence of groups only on the matched variables. As a consequence,
the groups differed with respect to dietary habits, smoking, blood
cholesterol concentrations, and marital status, with the secular
group having greater risk, as the authors themselves report. The
multivariate analysis of mortality did not control for these factors.
Control for confounding and other covariates
also affects studies that report that religious behaviors and
experiences influence health outcomes. In some studies with large
databases, this problem can be addressed. Both the Alameda County
Study and the Tecumseh Community Health Study showed that frequency
of attendance at religious services was inversely associated with
mortality.[17,18] However, after control for all relevant covariates,
this relation held only for women. In another large study, attendance
at religious services was associated with increased functional
capacity in the elderly[19] but after control for appropriate
covariates, this relation held for only 3 of the 7 years in which
outcome data were collected. There was no effect on mortality.[20]
In a smaller study, religiousness predicted mortality in the elderly
poor but only among those in poor health.[21]
In many other studies, inadequate control for
important covariates points to significant findings when none
may exist. For example, Pressman and colleagues[22] reported that
among elderly women after surgical repair of broken hips, religiousness
was associated with better ambulation status at discharge. Although
the analysis controlled for severity of health condition, it did
not control for age, a critical variable when studying functional
capacity in the elderly.
In some cases, problems of interpretation arise
not so much in the original research but rather in secondary sources.
A case in point is a report by Comstock and Partridge,[23] frequently
cited as showing a positive association between church attendance
and health. However, as Comstock himself later reported, this
finding was probably due to failure to control for the important
covariate of functional capacity: people with reduced capacity
(and poorer health) were less likely to go to church.[24] This
latter study is rarely cited. Similarly, Koenig reports that a
study by Colantonio and colleagues[25] "found lower rates
of stroke in persons who attended religious services at least
once per week . . .".[26] However, this was only the case
for the univariate analysis and the effect disappeared after covariates
such as levels of physical function were added to the analysis.
Levin, in a review of a review, reported that 22 of 27 studies
of religious attendance and health showed a significant positive
relation,[27] despite his own previous assertion that associations
between attendance and health are highly questionable because
this research is characterized by numerous methodological problems
including the failure to adjust for confounders and covariates.[28]
Finally, many studies evaluate differences in
health indicators as a function of religious denomination (eg,
ref 29-31). However, they are generally conducted precisely because
religious groups differ on risk behaviors such as smoking and
alcohol consumption or on genetic heritage.
Failure to control for multiple comparisons
Many studies on religion and health fail to
make an adjustment for the greater likelihood of finding a statistically
significant result when conducting multiple statistical tests.
For example, one study reported that religious attendance was
inversely associated with high concentrations of interleukin-6
in the elderly.[32] However, interleukin-6 was one of eight outcome
variables and there was no attempt to control for multiple comparisons,
as the authors themselves reported. In a retrospective study,[33]
the associations between frequency of prayer and six items measuring
subjective health were examined. Analyses of variance were conducted
on each of these six perceptions of health and three revealed
effects of frequency of prayer at the 0.05 level of statistical
significance. In such studies, adjustments of levels to control
for such multiple comparisons would render these findings
non-significant.
There are similar problems in the only published
randomized clinical trial.[34] In this double-blind study, patients
in a coronary-care unit (CCU) were assigned randomly either to
standard care or to daily intercessory prayer ministered by three
to seven born-again Christians. 29 outcome variables were measured,
and on six the prayer group had fewer newly diagnosed ailments.
However, the six significant outcomes were not independent: the
prayer group had fewer cases of newly diagnosed heart failure
and of newly prescribed diuretics and fewer cases of newly diagnosed
pneumonia and of newly prescribed antibiotics. There was no control
for multiple comparisons, a fact recognized by the author. To
address this issue, "multivariant" analysis was conducted
but the results were not presented, except for a p value for overall
model.
Conflicting findings
Published work on religion and health lacks
consistency, even among well-conducted studies. For example, while
Idler and Kasl found some effects of religious attendance on functional
capacity in the elderly, measures of "religious involvement",
an index of the "private, reflective" aspects of religion,
were not associated with any health outcome. Neither church attendance
nor religious involvement was associated with lower mortality.[20]
However, in two other large studies,[17,18] church attendance
was associated with lower mortality, but only in women.
Inconsistencies also arise within studies not
based on large epidemiological samples. For instance, when each
individual item from the scale of religiousness used by Idler
and Kasl, was used in another study, "religious comfort and
strength" was significantly associated with lower mortality
after cardiac surgery in the elderly even after control for relevant
confounders.[35] However, the other items from this scale, including
religious attendance, did not predict mortality. Moreover, when
the entire scale was used, the relation between religion and mortality
failed to reach significance. Byrd[34] reported an advantage in
hospital course for the group receiving prayer compared with the
control group. However, the groups did not differ in days in the
CCU, length of stay in hospital, and number of discharge medications.
While total cholesterol concentrations were lower across all age
groups for a cohort of Seventh Day Adventists (SDAs) than in age-matched
healthy New York City men and women, suggesting a lower risk of
coronary heart disease among SDAs, serum triglycerides of the
SDA men in the coronary-prone age range (>32 years) were 19%
higher than in the controls, which suggests the opposite.[29]
To some degree, lack of consistency is characteristic
of an evolving field and may be the product of differences in
study design, definitions of religious and spiritual variables,
and outcome variables. The absence of specific definitions of
religious and spiritual activity is an important problem, since
many of the studies to which we refer define these activities
differently. Published research would be substantially improved
with better definitions of these terms. However, inconsistency
in the empirical findings makes it difficult to support recommendations
for clinical interventions.
Ethical issues
Health professionals, even in these days of
consumer advocacy, influence patients by virtue of their medical
expertise. When doctors depart from areas of established expertise
to promote a non-medical agenda, they abuse their status as professionals.
Thus, we question inquiries into a patient's spiritual life in
the service of making recommendations that link religious practice
with better health outcomes. Is it really appropriate, as Matthews
and colleagues[9] recommend, for a physician to ask patients what
he or she can do to support their faith or religious commitment?
A second ethical consideration involves the
limits of medical intervention. If religious or spiritual factors
were shown convincingly to be related to health outcomes, they
would join such factors as socioeconomic status and marital status,[38]
already well established as significantly associated with health.
Although physicians may choose to engage patients in discussions
of these matters to understand them better, we would consider
it unacceptable for a physician to advise an unmarried patient
to marry because the data show that marriage is associated with
lower mortality.[38] This is because we generally regard financial
and marital matters as private and personal, not the business
of medicine, even if they have health implications. There is an
important difference between "taking into account" marital,
financial, or religious factors and "taking them on"
as the objects of interventions.
A third ethical problem concerns the possibility
of doing harm. Linking religious activities and better health
outcomes can be harmful to patients, who already must confront
age-old folk wisdom that illness is due to their own moral failure.[37]
Within any individual religion, are the more devout adherents
"better" people, more deserving of health than others?
If evidence showed health advantages of some religious denominations
over others, should physicians be guided by this evidence to counsel
conversion? Attempts to link religious and spiritual activities
to health are reminiscent of the now discredited research suggesting
that different ethnic groups show differing levels of moral probity,
intelligence, or other measures of social worth.[37] Since all
human beings, devout or profane, ultimately will succumb to illness,
we wish to avoid the additional burden of guilt for moral failure
to those whose physical health fails before our own.
Some practitioners who link faith and medical
practice do so appropriately, and in ways that do not depend on
utilitarian expectations of better health. For instance, devout
health professionals may view their work as an extension of their
religious beliefs. Such physicians may or may not choose to share
their opinions with patients. However, some patients and doctors
may be aware of a common faith. There is no ethical objection
to co-worshippers discussing medical issues in the context of
a shared faith. Indeed, a thorough understanding of a patient's
religious values can be extremely important in discussing critical
medical issues, such as care at the end of life. Irrespective
of the practitioner's religion, respectful attention must be paid
to the impact of religion on the patient's decisions about health
care.[38]
An especially poignant example of the devout
practitioner who appropriately notes connections between illness,
recovery, and prayers of thanks is provided by Prager, in describing
a serious illness in his son.[41] Prager does not suggest that
his son recovers function because he is faithful, but rather teaches
how the faithful may give thanks for recovery. Such connections
between faith and health are valuable because they are sensitive
to all aspects of the patient's experience, yet in no way depend
on spurious claims about scientific data.
Conclusions
Even in the best studies, the evidence of an
association between religion, spirituality, and health is weak
and inconsistent.
We believe therefore that it is premature to
promote faith and religion as adjunctive medical treatments. However,
between the extremes of rejecting the idea that religion and faith
can bring comfort to some people coping with illness and endorsing
the view that physicians should actively promote religious activity
among patients lies a vast uncharted territory in which guidelines
for appropriate behavior are needed urgently.
Nonetheless, caution is required. There is a
temptation to conclude that this matter can be resolved as soon
as methodologically sound empirical research becomes available.
Even the existence of convincing evidence of a relation between
religious activity (however defined) and beneficial health outcomes
may not eliminate the ethical concerns that we raise here. Religious
pursuits, such as decisions to marry or have children, are qualitatively
different from health behaviors such as quitting smoking or eating
a low-fat diet, even if they are linked unequivocally to health
benefits.
No-one can object to respectful support for
patients who draw upon religious faith in times of illness. However,
until these ethical issues are resolved, suggestions that religious
activity will promote health, that illness is the result of insufficient
faith, are unwarranted.
We gratefully acknowledge the contributions
of the many colleagues and friends who reviewed this manuscript.
--------------------------------------------------------------------------------
References
- Levin JS, Larson DN, Puchalski CM. Religion
and spirituality in medicine: research and education. JAMA 1997;
278: 792-93.
- McNichol T. The new faith in medicine. USA
Today. April 7, 1996: 4.
- Eisenberg DM, Kessler RC, Foster C, Norlock
FE, Calkins DR, Delbanco TL.
Unconventional medicine in the United States: prevalence, costs,
and patterns of use. N Engl J Med 1993; 328: 246-52.
- King DE, Bushwick B. Beliefs and attitudes
of hospital inpatients about faith healing and prayer. J Family
Practice 1994; 39: 349-52.
- Marwick C. Should physicians prescribe prayer
for health? Spiritual aspects of well-being considered. JAMA
1995; 273: 1561-62.
- Benson H. Timeless Healing. New York: Fireside,
1996.
- Matthews DA, Larson DB. Faith and medicine:
reconciling the twin traditions of healing. Mind/Body Medicine
1997; 2: 3-6.
- Sides H. The calibration of belief. New
York Times Magazine 1997; 92-95.
- Matthews DA, McCullough ME, Larson DB, Koenig
HG, Swyers JP, Milano MG. Religious commitment and health status.
Arch Family Medicine 1998; 7: 118-24.
- Michalek AM, Mettlin C, Priore RL. Prostate
cancer mortality among Catholic priests. J Surg Oncol 1981;
17: 129-33.
- Timio M, Lippi G, Venanzi S, et al. Blood
pressure trend and cardiovascular events in nuns in a secluded
order: a 30-year follow-up study. Blood Pressure 1997; 6: 81-87.
- Gardner JW, Lyon JL. Cancer in Utah Mormon
men by lay priesthood level. Am J Epidemiol 1982; 116: 243-57.
- de Gouw HWFM, Westndrop RGJ, Kunst AE, Mackenbach
JP, Vandenbrouke JP. Decreased mortality among contemplative
monks in the Netherlands. Am J Epidemiol 1996; 141: 771-75.
- Friedlander Y, Kark JD, Stein Y. Religious
orthodoxy and myocardial infarction in Jerusalem: a case control
study. Int J Cardiol 1986; 10: 33-41.
- Goldbourt U, Yaari S, Medalie JH. Factors
predictive of long-term coronary heart disease mortality among
10 059 male Israeli civil servants and municipal employees.
Cardiology 1993; 82: 100-21.
- Kark JD, Shemi G, Friedlander Y, Martin
O, Manor O, Blondheim SH. Does religious observance promote
health? Mortality in secular and religious kibbutzim in Israel.
AJPH 1996; 86: 341-46.
- House JS, Robbins C, Metzner HL. The association
of social relationships and activities with mortality: prospective
evidence from the Tecumseh Community Health Study. Am J Epidemiol
1982; 116: 123-40.
- Strawbridge WJ, Cohen RD, Shema SJ, Kaplan
GA. Frequent attendance at religious services and mortality
over 28 years. AJPH 1997; 87: 957-61.
- Idler EL, Kasl SV. Religion among disabled
and nondisabled persons II: Attendance at religious services
as a predictor of the course of disability. J Gerontol 1997;
52B: S306-S316.
- Idler EL, Kasl SV. Religion, disability,
depression, and the timing of death. Am J Sociol 1992; 97: 1052-1079.
- Zuckerman DM, Kasl SV, Ostfeld AM. Psychosocial
predictors of mortality among the elderly poor. Am J Epidemiol
1984; 119: 410-23.
- Pressman P, Lyons JS, Larson DB, Strain
JJ. Religious belief, depression and ambulation status in elderly
women with broken hips. Am J Psychiatry 1990; 147: 758-60.
- Comstock GW, Partidge KB. Church attendance
and health. J Chronic Dis 1972; 225: 665-72.
- Comstock GW, Tonascia JA. Education and
mortality in Washington County, Maryland. J Health Soc Behav
1977; 18: 54-61.
- Colantonio A, Kask SV, Ostfeld AM. Depressive
symptoms and other psychosocial factors as predictors of stroke
in the elderly. Am J Epidemiol 1992; 136: 884-94.
- Koenig HG. Is religion good for your health?
Binghamton, NY: Haworth Pastoral Press, 1997.
- Levin JS. Religion and health: is there
an association, is it valid, and is it causal? Soc Sci Med 1994;
38: 1475-82.
- Levin JS, Vanderpool HY. Is frequent religious
attendance really conducive to better health?: toward an epidemiology
of religion. Soc Sci Med 1987; 24: 589-600.
- Walden RT, Schaefer LE, Lemon FR, Sunshine
A, Wynder EL. Effect of environment on the serum cholesterol-triglyceride
distribution among Seventh-day Adventists. Am J Med 1964; 36:
269-76.
- Rasanen J, Kauhanen J, Lakka TA, Kaplan
GA, Salonen JT. Religious affiliation and all-cause mortality:
a prospective population study in middle-aged men in eastern
Finland. Int J Epidemiol 1996; 25: 1244-49.
- Lyon JL, Gardner K, Gress RE. Cancer incidence
among Mormons and non-Mormons in Utah (United States) 1971-85.
Cancer Causes Control 1994; 5: 149-56.
- Koenig HG, Cohen HG, George LK, Hays JC,
Larson DB, Blazer DG. Attendance at religious services, interleukin-6,
and other biological parameters of immune function in older
adults. Int J Psychiatry Med 1997; 27: 233-50.
- Levin JS, Lyons JS, Larson DB. Prager and
health during pregnancy: Findings from the Galveston Low birthweight
Survey. Southern Med J 1993; 86: 1022-27.
- Byrd RC. Positive therapeutic effects of
intercessory prayer in a coronary care unit population. Southern
Med J 1988; 81: 826-29.
- Oxman TE, Freeman DH, Manheimer ED. Lack
of social participation or religious strength and comfort as
risk factors after cardiac surgery in the elderly. Psychosomatic
Med 1995; 57: 5-15.
- Sorlie PD, Backlund E, Keller JB. US mortality
by economic, demographic, and social characteristics: the National
Longitudinal Mortality Study. AJPH 1995; 85: 949-56.
- Gould SJ. The mismeasure of man. New York:
Norton, 1981.
- Powell T. Regligion, race, and reason. J
Clin Ethics 1995; 6: 73-77.
- Prager K. For everything a blessing.
JAMA 1997; 277: 1589.
Return To Faith
& Health Connection Main Menu | Go
To Next Article
|
