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Is Spirituality Good Medicine?
Bridging the Divide Between Science and Faith

by Barbara Gabriel

Christina M. Puchalski, M.D.

At a time when technological advancements in modern medicine grab daily headlines and promise treatments for previously incurable diseases, there is a quiet revolution occurring in medical education. In a rapidly growing number of American medical schools, the study of spirituality is claiming a legitimate place in the curriculum. This study of issues of faith within the academic halls of science represents to many a return to the roots of medical practice - one that addresses both the spiritual and physical well-being of the patient.

In its isolation of things scientific from things spiritual, Western medicine has created the mind/body divide. Now a growing number of medical educators are advocating a reunion of the body and spirit in modern medicine. Can the study of medicine and spirituality coexist? Or is medicine best kept discrete from the intangible tenets of personal belief systems?

Spirituality in the Classroom

"There's a big interest in spirituality in our culture," says Christina M. Puchalski, M.D., assistant professor of Medicine at George Washington University School of Medicine and Health Sciences and director of Education at the National Institute for Healthcare Research (NIHR), a nonprofit organization that supports the study of relationships between spirituality and health. She teaches courses at both George Washington and Georgetown University School of Medicine on spirituality and medicine.

For the past four years, the NIHR, the George Washington Medical Center, and the AAMC have co-sponsored an annual conference for medical educators on spirituality and health. This year's conference, "Issues of Culture and End of Life in Medical Education," was held in September and, among other things, presented participants with curricular development information for courses on spirituality as it relates to patient-centered care, end-of-life care, and respect for patients' cultural and spiritual beliefs.

During the conference, more than $300,000 in Spirituality and Medicine Curricular Awards were granted. Funded by the John Templeton Foundation and distributed by the NIHR, the awards recognize model programs in spirituality and health in undergraduate medical curricula, psychiatric residency training, and primary care residency training.

Dr. Puchalski says the focus on technological aspects of medicine has left physicians and patients wanting more. "We still want to be good at making diagnoses, we want to have the technological expertise, but I think physicians want to give something else to their patients, and that is where the spiritual dimension comes in. There's a high burnout rate among physicians because of the pressures and changes in medicine. Some feel their profession is losing meaning."

Physicians who take time to address patients' spiritual needs by taking their "spiritual histories" - asking them questions about what gives their lives meaning and what coping mechanisms they rely on - can both restore meaning to their profession and practice better medicine, Dr. Puchalski says.

To illustrate her conviction that physicians' knowledge of their patients' personal belief systems can aid in treatment, Puchalski tells the following story: "I once had a patient diagnosed with HIV who felt she had brought the disease on herself, that she had sinned and God was punishing her. As a result, she did not want to go ahead with any treatment plan. I didn't realize why she was so adamant about not taking her medications until I asked about her spiritual history. Because I asked her, I was able to get her help from a trained chaplain. Had I not addressed those issues, I would never have been able to figure out a way to help her."

Lynn C. Epstein, M.D., associate dean of Medicine at Brown University School of Medicine and professor of the course "Inward Bound: Spirituality and Medicine," says that addressing a patient's sense of spirituality allows physicians to maximize their effectiveness as healers. "When people are sick, it's quite understandable that they will want to turn to whatever supports they have in their lives, and we as physicians need to assist patients in connecting with those supports," Dr. Epstein says. "When you ask patients what gives their lives meaning, you're trying to customize their treatment so that it allows them to continue their lifestyles in a way that makes their lives worth living."

According to the latest survey conducted by the NIHR, approximately 70 U.S. medical schools address issues of spirituality in their curricula. Dr. Puchalski, like many other professors of spirituality in medical schools, sees this as a return to holistic medicine. She and her colleagues agree that "spirituality" should be treated as a broad term, addressing multiple parts of a person's life, and not confined to organized religion.

"We define spirituality in the broadest sense possible," says Lura Pethtel, co-manager of the course "Spirituality: The Doctor-Patient Relationship" at Northeastern Ohio Universities College of Medicine. "It can include family, work, community - wherever the patient finds meaning in life."

Dr. Epstein adds that asking about a patient's personal belief system can help physicians learn the ways in which their patients' backgrounds and beliefs influence their reactions to their illnesses and the treatment options they will or will not consider. "To ask about a patient's spiritual history is to enable us to increase our understanding of patients in a diverse population," Dr. Epstein explains. "American society is increasingly culturally diverse. We can no longer assume we are familiar with the backgrounds of our patients."

Does Religion Improve Health?

When Howard University medical students enter the classroom of Martin Jones, M.D., they are exposed to music and slides of fine art that are meant to elicit the traditional role of spirituality in medicine. One of the slides he shows is Rembrandt's "Tobias Healing His Father's Blindness." "It shows Tobias healing his father, and over Tobias' shoulder is an angel, implying that Tobias is relying on higher spiritual entities for guidance in treating his father," explains Dr. Jones, who is the director of the Spirituality and Medicine Program at Howard University College of Medicine and professor of the course "Faith and Medicine: The Spirit of Healing." "The image helps students realize that as physicians they can rely on their spiritual reservoir to guide them through their duties as doctors."

Dr. Jones gives credence to studies suggesting a link between spiritual and religious practices and improved health outcomes, and he presents them to his students as empirical data that give hard evidence to the benefits of addressing a patient's spiritual needs. Among other things, these controversial studies have suggested that people who regularly attend religious services or engage in religious practices have lower blood pressure, recover more quickly from depression, have healthier immune systems, and experience fewer hospital stays.

"Some folks argue against such connections, but I believe they exist," says Northeastern Ohio Universities' Pethtel. "I believe researchers are finding the connections between spirituality and health."

Others are more cautious in evaluating such studies. Dr. Epstein suggests that it is not religion itself, but the correlative benefits of belonging to a religious community - such as having a built-in support network that one can rely on in times of distress - that lead to improved health outcomes. "It makes sense that people who are supported and thus experience less anxiety will show better outcomes," she says.Dr. Puchalski urges caution when interpreting data that purport to demonstrate causal relationships between religious practices and enhanced health. "We don't know what other factors are involved," she says. "It could be being part of an organized community; it could be that people who attend services on a regular basis are more likely to be compliant with medications. When people learn about these studies, they are often confused. I hear people say, 'My mother was a very religious person, and she died from cancer at age 35. Does that mean she wasn't religious enough?' That kind of message can be harmful to people. We really don't know if religion improves health outcomes."

A Voice of Dissent

Richard P. Sloan, Ph.D., critic of spirituality in curriculum

Richard P. Sloan, Ph.D., associate professor in the Department of Psychiatry at Columbia University College of Physicians and Surgeons, is an ardent critic of introducing spirituality into the medical school curriculum.

In a recent article published in the New England Journal of Medicine, Sloan and several co-authors challenge the validity of studies that suggest religious activities support health, saying that such studies contain "serious methodologic flaws, conflicting findings, and data that lack clarity and specificity." Sloan goes on to suggest that when a physician addresses spirituality or religion with a patient, the potential exists for doing more harm than good.

"The physician-patient relationship is not a symmetrical one," says Dr. Sloan, who is also the director of the Behavioral Medicine Program at the Columbia-Presbyterian Medical Center in New York and chief of the Department of Behavioral Medicine at the New York State Psychiatric Institute. "Patients are subordinate in that relationship, and that asymmetry derives from the physician's medical expertise. We're expected as patients to follow physician recommendations.

"When a physician says, 'You should go on a low-fat diet,' or 'You should take this antibiotic,' patients are expected to follow that advice. Physicians who suggest that going to church or engaging in religious activity is good for your health are abusing their authority. Their recommendations can be coercive and threaten people's religious freedom."

Dr. Sloan argues against courses in medical school dedicated solely to issues of spirituality. He agrees that there is a need to teach future physicians how to treat their patients as whole human beings rather than "collections of organs, systems, and tissues." But, he says, a patient's spirituality is just one of many aspects in his or her life that influence behavior and should not be singled out.

"Most studies suggest that being married is much better for your health than not being married," Dr. Sloan says. "But we would never expect a physician to tell a single patient that he or she should marry. We recoil at that kind of advice because we regard decisions about marital status as personal and private and out of the domain of medicine, even if marital status is associated with health outcomes. Similarly, there is substantial evidence that early rather than later childbearing confers reduced risk of certain cancers. But we don't expect physicians to tell us to have children sooner rather than later because we regard decisions about childbearing to be personal and private. Decisions about religion are even more personal and private."

Although they may not agree with all of Dr. Sloan's arguments, Dr. Puchalski and her colleagues do agree that physicians should not abuse their positions of authority by proselytizing to their patients. "We need to ask ourselves if we are acting in the interest of the patient or pushing our own agenda," Dr. Puchalski says. "In any aspect of the doctor-patient relationship, it is the patient's well-being that should always come first."

Dr. Jones agrees. "We're not evangelists," he says. "We're not calling people to be ministers. This is about examining the potential spiritual awareness has for healing patients, body and soul."

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