Good grief Tim.
First it was fullsome (not to say frenzied) favoring of the fantastic
effects of faith; then, as I collect, you followed it up by boldly
blustering on the beauty of belief.
TheHermit
"Who was that masked man? A crimson streak across the dark sky above the
forest full of endagered species. Who is he, and why has he never been
photographed with handsome, unblinking millionaire Al Gore?"
> -----Original Message-----
> From: owner-virus@lucifer.com
> [mailto:owner-virus@lucifer.com]On Behalf
> Of Tim Rhodes
> Sent: Thursday, March 11, 1999 2:47 AM
> To: virus@lucifer.com
> Subject: Re: virus: Brave New World
>
>
>
>
>
> On Wed, 10 Mar 1999, Eric Boyd wrote:
>
> > How many level 3 people will
> > become Janitors?
>
> As many as want to be. When you know the way power really
> works you also know
> better than to think that it resides only in the top of a hierachy.
>
> -Prof. Tim
>
>
>
I am on a mail list where I received a brief note about this and it looked
interesting, so I pulled the rest from the Lancet site. The Lancet is
unfortunately one of those subscriber only and register to access to access
anything but abstracts type sites, so here it is in a more accessible form
for anyone who is interested. The horses mouth as far as peer reviewed
current medical opinion re Religion, spirituality, and medicine. I have the
original document in its HTML format where the cross-references work. Anyone
who would like it should just drop me an off-list note.
Studies over the past several years and "religiously" reported on the CoV
mail list and other forums have reported that people who believe in God, who
are religious, who pray, or who hold strong "spiritual" affinities, have
lower blood pressure, recover from diseases and surgery faster, have greater
longevity, and in general show many indicators of superior general health.
In other words, spiritual health equals physical health. Skeptics have
responded that the effect is most likely due to psychological reasons such
as the placebo effect and self-fulling prophecies, or social psychological
reasons, such as familysupport and encouragement to take needed medications,
lead a healthier life style ("no, no honey, the doctor said you can't have
the extra rich Ben and Jerry's ice cream"), etc.
A study published in the February 20, 1999 issue of The Lancet (Vol. 353:
664-667) calls all of this into question and challenges the original studies
themselves. The authors, Richard Sloan, E. Bagiella, and T. Powell, all from
Columbia University, present a comprehensive examination of the empirical
evidence and ethical issues involved in claims for a religion-medicine
connection. The authors begin by noting that 79% of Americans report they
believe that spiritual faith can aid recovery, 63% believe physicians should
talk to their patients about spiritual faith, 48% want their doctors to pray
with them, and 25% reported using prayer as part of their therapy. Nearly 30
U.S. medical schools offer courses on religion, spirituality, and health. Of
296 physicians at a meeting of the American Academy of Family Physicians,
99% said they believe religious beliefs aid healing, and a remarkable 75%
reported that they believe that prayer by one person can actually help
someone else recover from an illness. But the authors point out a number of
methodological problems:
The authors also point out that most studies did not provide definitions of
religious and spiritual variables, nor of 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." Sloan, Bagiella, and Powell conclude: "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."
TheHermit
>From
Volume 353, Number 9153 20 February 1999
Religion, spirituality, and medicine
R P Sloan, E Bagiella, T Powell
Lancet 1999; 353: 664-67
Behavioral 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
Correspondence to: Dr Richard P Sloan, Columbia University, Box 427, 622
West 168th St, New York 10032 (e-mail rps7@columbia.edu)
Interest in connecting religion and medicine
Empirical evidence
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
characterised 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 spirituality1 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.
http://www.thelancet.com/newlancet/reg/issues/vol353no9153/menu_NOD999.html
Ethical issues
Conclusions
References
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 favourably 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 behaviours, 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 behaviours. Here, we consider methodological issues that pertain to studies of physical disease outcomes.
Control for confounding variables and other covariates Confounders such as behavioural 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 behaviours 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 these14 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 behaviours 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 elderly19 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 colleagues22 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 colleagues25 "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 characterised 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 behaviours 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 randomised 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 recognised 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. Byrd34 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 colleagues9 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 physicans 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 behaviour 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 behaviours 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
1 Levin JS, Larson DN, Puchalski CM. Religion and spirituality in medicine: research and education. JAMA 1997; 278: 792-93.
2 McNichol T. The new faith in medicine. USA Today. April 7, 1996: 4.
3 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.
4 King DE, Bushwick B. Beliefs and attitudes of hospital inpatients about faith healing and prayer. J Family Practice 1994; 39: 349-52.
5 Marwick C. Should physicians prescribe prayer for health? Spiritual aspects of well-being considered. JAMA 1995; 273: 1561-62.
6 Benson H. Timeless Healing. New York: Fireside, 1996.
7 Matthews DA, Larson DB. Faith and medicine: reconciling the twin traditions of healing. Mind/Body Medicine 1997; 2: 3-6.
8 Sides H. The calibration of belief. New York Times Magazine 1997; 92-95.
9 Matthews DA, McCullough ME, Larson DB, Koenig HG, Swyers JP, Milano MG. Religious commitment and health status. Arch Family Medicine 1998; 7: 118-24.
10 Michalek AM, Mettlin C, Priore RL. Prostate cancer mortality among Catholic priests. J Surg Oncol 1981; 17: 129-33.
11 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.
12 Gardner JW, Lyon JL. Cancer in Utah Mormon men by lay priesthood level. Am J Epidemiol 1982; 116: 243-57.
13 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.
14 Friedlander Y, Kark JD, Stein Y. Religious orthodoxy and myocardial infarction in Jerusalem: a case control study. Int J Cardiol 1986; 10: 33-41.
15 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.
16 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.
17 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.
18 Strawbridge WJ, Cohen RD, Shema SJ, Kaplan GA. Frequent attendance at religious services and mortality over 28 years. AJPH 1997; 87: 957-61.
19 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.
20 Idler EL, Kasl SV. Religion, disability, depression, and the timing of death. Am J Sociol 1992; 97: 1052-1079.
21 Zuckerman DM, Kasl SV, Ostfeld AM. Psychosocial predictors of mortality among the elderly poor. Am J Epidemiol 1984; 119: 410-23.
22 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.
23 Comstock GW, Partidge KB. Church attendance and health. J Chronic Dis 1972; 225: 665-72.
24 Comstock GW, Tonascia JA. Education and mortality in Washington County, Maryland. J Health Soc Behav 1977; 18: 54-61.
25 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.
26 Koenig HG. Is religion good for your health? Binghamton, NY: Haworth Pastoral Press, 1997.
27 Levin JS. Religion and health: is there an association, is it valid, and is it causal? Soc Sci Med 1994; 38: 1475-82.
28 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.
29 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.
30 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.
31 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.
32 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.
33 Levin JS, Lyons JS, Larson DB. Prayer and health during pregnancy: Findings from the Galveston Low birthweight Survey. Southern Med J 1993; 86: 1022-27.
34 Byrd RC. Positive therapeutic effects of intercessory prayer in a coronary care unit population. Southern Med J 1988; 81: 826-29.
35 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.
36 Sorlie PD, Backlund E, Keller JB. US mortality by economic, demographic, and social characteristics: the National Longitudinal Mortality Study. AJPH 1995; 85: 949-56.
37 Gould SJ. The mismeasure of man. New York: Norton, 1981.
38 Powell T. Regligion, race, and reason. J Clin Ethics 1995; 6: 73-77.
39 Prager K. For everything a blessing. JAMA 1997; 277: 1589