Prescribing prayer? 'Say the rosary & call me in the morning'.

Increasingly, claims are being made about the positive effect of "spirituality" on the sick and even for the "proven" benefits of intercessory prayer. Some prominent voices in medicine are now urging that the spiritual values of patients be taken more seriously in devising treatment plans. Other leading figures in the spirituality and health literature are even more assertive. They suggest that failing to pray for patients may, in the not-too-distant future, be seen as a form of "medical malpractice."

It is hard to know what to make of all this. Obviously, spiritual and religious values are central to the experience of many patients, and chaplains have long been vital players in any team approach to health care. More broadly, there are undeniable historical links between faith and curing. The New Testament describes many miracles, and similar stories are part of most religious traditions. Yet it is important to see miracles for what they are--abrogations of the laws of nature. That is why it is unclear what bearing such exceptions should have on the practice of a scientifically based medicine.

But wait, some will object, we're talking about "spirituality," not miracles. Many people, disappointed with institutional religion, prefer to speak the language of spirituality. Spirituality is a very elastic term used to describe a host of variable beliefs: it can be used to describe belief in a "transcendent power," or in "what gives life meaning," or (if Godtalk is an embarrassment) a "confidence in the human spirit." It is hardly obvious how so malleable a term can be measured with rigor or confidence by the standards of medical research.

Those writing about spirituality and health also tend to conflate "healing" and "curing." The two, while often synonymous, are not always the same. "Cure rates" are measurable according to scientific, clinical, and epidemiological criteria, and have to do with the eradication or at least reversal of underlying pathologies. Healing is a more individualized and holistic term. Thus, hospice patients might well be healed--in other words, brought to a sense of acceptance of their condition--even as they die from terminal illness. Other patients, even when cured of an illness, may not be healed in the broader psychological sense. The links proposed between health and spirituality (or religion) would be more credible if the sometimes subtle differences between healing and curing were kept in mind. For many patients, religious and spiritual values are probably central, even decisive, elements in healing; but whether such values play a role in curing them, in the narrower sense, remains an open question.

Luminaries in the spirituality-and-health movement also tend to "genericize" their discussions of prayer and religious practice. It doesn't matter to whom one prays, they argue. Thus, all forms of belief are physiologically equivalent. Studies support the fact that identical physiological benefits can be achieved whether you pray the Jesus Prayer, a Sanskrit mantra, or, for that matter, simply focus on your breathing. Such similar results are interesting, I suppose, but hardly theologically dispositive. Indeed, the conclusion that equal physiological outcomes are evidence for the equal standing of all religious and spiritual perspectives seems a curiously reductive form of ecumenism.

To be sure, you can customize your spirituality. In the spirit of self-help, you can become a spiritual consumer, assembling a patchwork of insights and practices with demonstrable health benefits. For anyone standing within a robust religious tradition, however, such a smorgasbord approach is suspect on two grounds: first, because it may emerge as the spiritual form of an individualism already too prevalent in the culture; second, because it may deform the richer meaning of religious practices by reducing them to health technologies.

Is there, in fact, unambiguous evidence for the effects of particular religious beliefs on health outcomes? There are, I admit, broad correlations that can be drawn. For example, Seventh Day Adventists are healthier than many other groups; however, avoiding nicotine and red meat, as Adventists do, is known to be good for your health, whatever your motivation. And I don't doubt that churchgoers do better than shut-ins on broad measures of health, though again, sociability is probably good for you, whatever your faith or lack of it. Other studies suggest that intercessory prayer generates measurable benefits for patients who are randomly prayed for, although these data have been faulted for their statistical shortcomings. Yet my scientist friends remind me that in both broad epidemiological research and more limited clinical studies the possible causes of restored health are at present "overdetermined." In scientific terminology, that means claims about religious belief as an independent cause of cures remain highly controversial.

Why should any of this be especially troubling? After all, I'm sympathetic to the need to respect patients' values, including religious and spiritual concerns. Still, I wonder about the ethical implications for caregivers of the new emphasis on spirituality and health. We need compassionate physicians, maybe even doctors who in some settings will pray with, as well as for, patients. Doctors, whatever their own outlook, should be far more sensitive than they often are to the importance of religion and spirituality for many patients. But it would be as much a mistake to expect physicians to assume the role of religious or spiritual counselor as to expect chaplains to interpret lab values. Rather than ask physicians to take on a new set of responsibilities, we should work to ensure that chaplains, social workers, nurses, and other professionals are fully respected and integrated members of the healing team.