Introduction.

Compassionate patient care should be an integral part of the medical profession. Unfortunately, while medicine is making tremendous technologic advances, the potential for offering compassionate care is decreasing. Patients and their families may be intimidated by the health care delivery system and modern technology-based treatment. (1) The current health care system consists largely of fragmented, specialized care for specific problems rather than a holistic approach to treatment. Economic pressures are also affecting all health care professionals and decreasing the time they can spend with patients. Physicians and other medical professionals face new demands and are under increasing stress.

Part of the process of humanizing health care is considering an individual's unique psychosocial resources, including their spirituality, during illness and recovery. Most patients use their faith to cope with their illness and often report an increased sense of spiritual need. (2) Nurses see spirituality as important to their patients' welfare, and they report that they frequently encounter patients who request it. (3) As noted by Gibbons and Miller, (4) "when hospitals ignore the spiritual dimension of patient care, they risk them becoming biologic garages where dysfunctional human parts are repaired or replaced."

Religious community and spiritual practices are important aspects of the lives of a substantial portion of the US population. According to a Gallup poll, approximately 70% of Americans are members of a church or synagogue, 82% of adults feel a need for spiritual growth in their lives, and these numbers are higher in the American South. (5) Three out of five Americans consider religion "very important" to themselves, 80% indicate that they use prayer in times of crisis, and 95% of those who use prayer believe that their prayers are answered. These rates of religious interest have remained fairly constant in the United States from the mid 1960s through the 1990s. (5)

Researchers at the Mayo Clinic recently documented findings indicating that religion plays an important role for many people coping with illness. (6) A number of studies of hospitalized patients have shown an inverse relation between the use of religious or spiritual coping behaviors and depressive symptoms that are commonly associated with stress and illness. Koenig (7) found that religious coping (prayer, reading scriptures, relying on God for support) was the most important factor in helping patients cope with illness, with nearly 90% indicating that they used religion at least moderately. Faith can offer a sense of control over feelings of helplessness, along with providing the natural social support of community.

The article, "Religion, Spirituality and Medicine: Research Findings and Implications for Clinical Practice," by Harold Koenig (8) of the Duke Medical Center, addresses what he believes practicing physicians can and should do in clinical practice, given the scientific research demonstrating a connection between religion, spirituality, and both mental and physical health. Dr. Koenig notes that this is an area that makes many physicians uncomfortable, since there has only been training in medical schools on these issues within the past 5 years. (9) Not only do physicians lack training, but they are also worried about spending the extra time, since they are uncertain about the benefits. Furthermore, they are concerned about overstepping ethical boundaries in the doctor-patient relationship. (10) While these concerns are valid, Koenig makes a persuasive case that spiritual issues can be successfully and practically addressed. Taking a spiritual history, supporting the patient's beliefs, and orchestrating the treatment of spiritual needs are among the topics that this article will address. (11)

Kenneth Pargament and colleagues in their article "Religion and HIV: A Review of the Literature and Clinical Implications" (12) review the links between various dimensions of religiousness, well-being, and spiritual struggles among people suffering from HIV/AIDS. This carefully crafted article describes the development of an eight-session, psycho-spiritual intervention group for women who have been diagnosed with HIV/AIDS. The intervention grows out of interviews with HIV/AIDS patients about the impact of the disease on their spirituality. A treatment is described that integrates spirituality into seven critical issues common to women dealing with HIV/AIDS: healing, body and spirit, control and surrender, letting go of anger, shame and guilt, intimacy and isolation, and hopes and dreams. The intervention illustrates the promising potential of religiously integrated approaches to treatment for people suffering from major illnesses.

Andrew Weaver and Kevin Flannelly in their article entitled, "The Role of Religion/Spirituality for Cancer Patients and Their Caregivers," (13) evaluate the strengths and weaknesses of the research on religious/spiritual coping and cancer. Cancer is the second leading cause of death, resulting in more than 550,000 deaths, or 1 of every 4 Americans who die each year. (14) A diagnosis of cancer challenges every dimension of a person's life--physical, emotional, and spiritual. Researchers have found a strong relation between patients' reliance on religious belief and practice and their ability to cope with cancer. (15, 16) They point out that faith can give a suffering person a framework for finding meaning and perspective. Spiritual well-being among cancer patients has been associated with the ability to enjoy life even while experiencing negative symptoms. (17) They also examine the limitations of the current research in this important area.

Neal Krause of The University of Michigan, examines the impressive body of research suggesting that older people who are more involved in religion tend to enjoy better physical and mental health than older individuals who are not involved in religion. His article, "Religion, Aging and Health: Exploring New Frontiers in Medical Care," (18) also appraises a number of gaps in this research. His review begins with the basic premise that religion is a complex multidimensional phenomenon that involves a wide range of behavior and beliefs, including prayer, worship attendance, and the maintenance of social ties with fellow faith community members. In addition, a special emphasis is placed on exploring variations by race; specifically, an effort is made to examine the ways in which religion is an especially important source of resilience for many older black Americans.

Robert Hummer, Christopher Ellison, and their colleagues at the University of Texas contribute an article entitled "Religious Involvement and Adult Mortality in the United States: Review and Perspective." (19) They note that there is a long tradition of sociological research surrounding the association between religion and mortality. Recently, scholars have linked measures of religious involvement with mortality outcomes and have examined some of the reasons why these associations exist. Some of this work indicates a protective effect of religious involvement against the risk of death among US adults. Nevertheless, this area of research remains underdeveloped theoretically and methodologically. Only recently have population-based data sources become available that allow an inquiry into the association between religious involvement and mortality at the national level. In addition, only very limited research has considered the effects of religious involvement on mortality rates within subgroups of the population. In response to these deficiencies, this paper reviews the medical, public health, and social science literature that has empirically addressed the religion-mortality linkage to date. Importantly, it discusses how future scientific work in this area might best proceed.

Andrew Weaver and his colleagues examine three leading medical journals (Journal of the American Medical Association, Lancet, and the New England Journal of Medicine) between 1998 and 2000 for research referencing the role of religion/spirituality. In "Religion and Spirituality in Three Major General Medical Journals from 1998 to 2000," (20) Weaver et al report finding that of the 2,385 studies published, only 20 examined some aspect of spirituality or religion. The percentage of quantitative studies that contained a religious or spiritual variable (0.8%) was lower than that found in similar systematic reviews of journals in other clinical disciplines. (21) Religious variables were a key element of most studies that did measure it. Overall, however, little attention is paid to these concepts in general medical journals, even though they may be useful for refining outcomes research.

Lastly, Kevin Flannelly and colleagues contribute a valuable and practical article titled "Methodological Issues in Research on Religion and Health." (22) They skillfully examine several methodologic issues in the area of research on religion and health, and discuss how clinicians can assess the quality of research for themselves. They explain and explore basic research concepts, including the measurement of the concept of religion, research designs, sampling, and statistical controls for determining the effects of religion on health outcomes. They helpfully assess differences in analytical perspectives that have contributed to the debate about the effects of religion on health. The authors also discuss some of the methodological problems of past research and address what needs to be done to enhance the quality of the research. They highlight the basic findings in the field, and illustrate how the methodology used in studies of religion and health has improved over time.

Everything has been figured out, except how to live.
--Jean-Paul Sartre

Accepted February 3, 2004.

References

1. Humphrey LJ. New insights on the emotional responses of cancer patients and their spouses: where do they find help? J Pastoral Care 1995;49:149-157.

2. Mickley R, Soeken K, Belcher A. Spiritual well-being, religiousness and hope among women with breast cancer. Image 1992;24:267-272.

3. Taylor EJ, Highfield M, Amenta M. Attitudes and beliefs regarding spiritual care. Cancer Nursing 1994;17:479-487.

4. Gibbons JL, Miller SL. An image of contemporary hospital chaplaincy. J Pastoral Care 1989;43:355-361.

5. Gallup GG, Lindsay DM. Surveying the Religious Landscape: Trends in US Beliefs. Harrisburg, PA, Morehouse Publishing, 1999.

6. Mueller P, Plevak D, Rummans T. Religious involvement, spirituality, and medicine: subject review and implications for clinical practice. Mayo Clinic Proc 2001;76:1766-1771.

7. Koenig HG. Religious beliefs and practices of hospitalized medically ill older adults. Int J Geriatr Psychiatry 1998;13:213-224.

8. Koenig HG. Religion, spirituality, and medicine: research findings and implications for clinical practice. South Med J 2004;97:1194-1200.

9. Puchalski CM, Larson DB, Developing curricula in spirituality and medicine. Acad Med 1998;73:970-974.

10. Astrow AB, Puchalski C. Sulmasy DP. Religion, spirituality and health care: social, ethical, and practical considerations. Am J Med 2001;110:283-287.

11. Koenig HG. An 83-year-old woman with chronic illness and strong religious beliefs. JAMA 2002;288:487-493.

12. Pargament KI, Nalini T, McCarthy S, et al. Religion and HIV: a review of the literature and clinical implications. South Med J 2004;97:1201-1209.

13. Weaver AJ, Flannelly KJ. The role of religion/spirituality for cancer patients and their caregivers. South Med J 2004;97:1210-1214.

14. American Cancer Society. Cancer Facts and Figures 2000. Atlanta, GA, American Cancer Society, 2000.

15. Holland JC, Passik S, Kash KM, et al. The role of religious and spiritual beliefs in coping with malignant melanoma. Psychooncology 1999;8:14-26.

16. Ferhring RJ, Miller JF, Shaw C. Spiritual well-being, religiosity, hope, depression, and other mood states in elderly people coping with cancer. Oncol Nurs Forum 1997;24:663-671.

17. Brady MJ, Peterman AH, Fichett G, et al. A case for including spirituality in quality of life measurements in oncology. Psycho-oncology 1999;8:417-428.

18. Krause N. Religion, aging, and health: exploring new frontiers in medical care. South Med J 2004;97:1215-1222.

19. Hummer RA, Ellison CG, Rogers RG, et al. Religions involvement and adult mortality in the United States: review and perspective. South Med J 2004;97:1223-1230.

20. Weaver AJ, Flannelly KJ, Case DB, et al. Religion and spirituality in three major general medical journals from 1998 to 2000. South Med J 2004;97:1245-1249.

21. Weaver AJ, Flannelly L, Flannelly K, et al. A systematic review of research on religion in three major mental health nursing journals: 1991-1995. Iss Ment Health Nurs 1998;19:263-276.

22. Weaver AJ, Flannelly KJ, Strock AL. Methodological issues in research on religion and health. South Med J 2004;97:1231-1241.

RELATED ARTICLE

Adults in the United States:

* 82% feel a need for spiritual growth

* 80% use prayer in times of crises, and 95% believe their prayers are answered

* 70% are members of a church or synagogue

* 60% consider religion "very important" to themselves

RELATED ARTICLE: Key Points

* Three out of five Americans consider religion "very important" in their lives.

* Part of humanizing health care is considering an individual's spirituality.

* A number of studies of hospitalized patients have shown a relation between the use of religious or spiritual coping mechanisms and better health outcomes.

RELATED ARTICLE

Physicians:

* Lack training in spirituality-related issues

* Worry about spending extra time if uncertain of benefits

* Concerned that ethical boundaries may be overstepped

Andrew J. Weaver, PHD, and Christopher G. Ellison, PHD

These papers are dedicated to the late David B. Larson, M.D., who died on March 5, 2002, at age 54. As the founder and president of the International Center for the Integration of Health and Spirituality, he made an enormous contribution to a thoughtful dialogue between the medical and religious communities.

Reprint requests to Dr. Andrew Weaver, 260 18th Street, New York, NY 11215. Email: [e-mail]