In the popular press and medical literature, attention to the relationship of religion and spirituality to health increases every year.

In 1998 alone healthcare journals published over eighty articles on the subject written by physicians and nurses. Research on the efficacy of intercessory prayer commands attention, and an editorial in a prominent medical journal asked, "Should physicians prescribe prayer?" Other authors describe how physicians can gather a "spiritual history" from their patients. The Journal of Occupational Therapy recently published its second issue in the last decade devoted to spiritual concerns.

Older research on the topic focused almost entirely on religious faith and practice without much attention to spirituality. A patient's religion, including religious heritage, current affiliation, and worship attendance, is more easily gauged than spirituality, a more diffuse and entirely individual trait. Spirituality refers to a person's sense of ultimate meaning in life, the implicit or explicit responses to ultimate questions, such as "Who am I?" and "What is my purpose?"

Authors acknowledge the questionable quality of older research on the subject, yet report that religious variables are indeed often significantly related to better health. More recent studies are of better quality, although they are also criticized for not statistically controlling for variables that might confound results. It is evident that scientifically studying the relationship of religion and spirituality to health is difficult. Few studies of spirituality exist because scientists cannot agree on an acceptable definition, and research concerning religious faith and practice almost always focuses on Christianity, neglecting other faith traditions. Thus research that examines this relationship is not only varied, but also limited. It is widely understood that this research effort is in its infancy and that much difficult work remains.

Understandably, the positive results of some studies have led to claims that physicians ought to attend to the religious concerns of their patients. Some have written that physicians would thereby enhance their effectiveness. In a few instances, authors declare or imply that physicians risk medical negligence if they do not provide this attention.

Despite these claims and initial research efforts, some question whether the physician's role should include attention to spiritual concerns. Even if spirituality and religious faith and practice are healthful, they opine, such proposed physician activities pose ethical and professional difficulties. The concerns arise, in part, because spirituality, religious faith and practice, and delivery of medical care are all complex systems.

What is driving the advocacy that promotes physician attention to religious concerns? This discussion is really about more than whether physicians, who provide continuity of care, should assess spiritual history while screening new patients. Many physicians already gather religious preference data when a new patient completes a demographic form for the medical chart and likely ask about religious/spiritual concerns when talking with patients about their living will and health care power of attorney.

This increased interest is about something more: it implies that all physicians, presumably including sub-specialists and consultants, should initiate discussions that reach beyond medical screening. It suggests that physicians should begin to provide spiritual care. Such a claim is indeed new and merits attention.

This article describes five professional and ethical areas that require far more research before global claims can be made that physicians ought to begin providing spiritual care. Each of these areas reflect the complexities of providing spiritual services within health care settings.

First, the religious diversity of patients immediately presents concerns. Cultural and religious diversities abound and are widely distributed throughout the society. Even rural areas, once the bastion of Christianity, now often contain persons from a variety of religious and cultural heritages. Christian, Jewish, and Islamic groups are themselves widely diverse and possess unique beliefs and practices that influence how health problems are managed. While this diversity underscores the importance of physicians taking a spiritual history, it also points out the difficulty of instigating religious discussions or even praying with patients. Given the scientific emphasis of medicine, further research is needed to determine whether physicians can helpfully carry out such discussions.

Second, religious faith and practice are a source of conflict in the lives of many patients. Conflicts between Catholics and Protestants and among Christians, Jews, and Muslims continue not only within nations and ethnic groups, but also among families, and they affect individual patients. They are instigated by interfaith marriages, different interpretations of doctrinal issues, and disagreements about acceptable behaviors. Health care chaplains have learned that these conflicts create lingering doubts, fears, and antagonisms that lie just below the surface. Their inquiry about religious/spiritual concerns can initiate complicated and lengthy discussions. Thus, attention to religious concerns cannot be based on the assumption that this is a simple process that can be carried out on the basis of good intentions. Once again research is needed to determine whether medical providers can conduct such discussions helpfully.

The third area concerns whether identifiable interpersonal and intrapersonal skills are necessary to facilitate such conversations. To answer affirmatively simply raises questions of the nature of such skills and whether physicians possess them. Does current medical education, the physician's own religiousness, or interest in the patient's concerns provide such skills? In many ways, these skills are similar to those learned in psychotherapy or chaplaincy training and thus cast doubt on physician preparedness. Yet again, no published research has examined necessary physician skills. Self-declared expertise is likely not sufficient.

The fourth issue pertains to whether physicians can initiate discussions about religious concerns with patients without proselytizing. Physicians certainly must not encourage patients to convert to another religion. The deeper and equally serious question, however, is whether physicians can point to research results that, for example, demonstrate the healthful benefits of worship attendance or prayer without advocating these activities. It seems clear that the discussion of such research results implicitly endorses and recommends such behaviors. The question here is not whether this behavior should be encouraged, but rather whether it is appropriate for the physician to do so. The ethical problem is whether this constitutes an inappropriate use of medical authority.

The final difficulty follows from those discussed above. The professional role of medicine is circumscribed by its focus on health and illness. Physicians who engage patients in discussions about their religious concerns implicitly portray religion and spirituality as useful medical interventions. This utilitarian approach to religious faith and practice raises many questions that merit further attention. Patients certainly turn to their religion and spirituality to cope with illness, but they also likely regard their beliefs and practices as uniquely different from medical interventions. To introduce them as medical interventions, therefore, can trivialize religion and compromises its power to be helpful.

All of this notwithstanding, religion and spirituality cannot be totally separated from the medical practice of every physician. Patients will sometimes raise these concerns with physicians, who are then obligated to make some kind of response—even if they do not wish to engage in a discussion about faith. Additionally, some physicians also possess appropriate training to engage in these conversations (e.g., those who possess both a medical and theological education). Some physicians and patients worship together in a local faith community and know each other well enough that such conversations are appropriate. In general, however, much additional research and exploration are necessary before global claims that physicians ought to engage patients in the discussion of religious and spiritual concerns can be substantiated.

For Further Reading

• Cohen, C. B., et al. "Prayer as Therapy: A Challenge to Both Religious Belief and Professional Ethics." Hastings Center Report 30, no. 3 (May-June 2000): 40-47.
• Koenig, H. G., et al. "Religion, Spirituality, and Medicine: A Rebuttal to Skeptics." International Journal of Psychiatry in Medicine 29 no. 2 (1999): 123.
• Post, S. G., C. M. Puchalski, and D. B. Larson. "Physicians and Patient Spirituality: Professional Boundaries, Competency, and Ethics." Annals of Internal Medicine 132, no. 7 (4 April 2000): 578-583.
• Sloan, R. P., E. Bagiella, T. Powell. "Religion, Spirituality, and Medicine." The Lancet 353 (20 February 1999): 664-667.
• Sloan, R. P., et al. "Should Physicians Prescribe Religious Activities?" New England Journal of Medicine 342 no. 25 (1999): 1913-1916.
• VandeCreek, L. "Should Physicians Discuss Spiritual Concerns with Patients?" Journal of Religion and Health 38 no. 3 (1999): 193-201.

Larry VandeCreek is Co-Director of Pastoral Research at the HealthCare Chaplaincy, a large community-based pastoral care, education, and research center providing chaplaincy services in more than twenty health care centers in the New York City area.