Monthly Archives: May 2014

There is a growing recognition in medical education and practice that the spiritual component of human existence must be recognized and addressed. The American College of Physicians has concluded that physicians are obligated to attend to all dimensions of suffering—the physical, psychosocial, spiritual, and existential.[1] Similarly, the Joint Commission on Accreditation of Healthcare Organizations (JAHCO), which accredits hospitals, recognizes that spiritual concerns are often important for patients and that hospitals should provide spiritual care. [2] At the same time, some writers have expressed reservations about this movement to incorporate spirituality into health care. There is, for instance, concern that this could be a subtle effort to push religious ideas and values on to patients and providers.   Others question why medicine should be concerned about the spiritual aspect of human experience.[3] After all, what special expertise do physicians and other health professionals have in the area of spirituality? Even if it is granted that health care providers should recognize patients’ spiritual needs, how are they supposed to practically respond to them? This would seem to be a particularly complicated question to answer in our increasingly pluralistic society.

In this blog post, I will offer three reasons why physicians and other health practitioners should recognize and address the spiritual component of their patients’ lives.

The first reason is that understanding a patient’s spirituality is an important part of helping clarify and fulfill his or her goals of care. This is because a patient’s spirituality may significantly affect medical decision-making. For instance, a 2003 study asked patients with lung cancer to rank the importance of seven factors in their medical decision-making. The seven factors were the oncologist’s treatment recommendation, ability of treatment to cure disease, side effects, family doctor’s recommendation, the spouse’s recommendation, children’s recommendation, and faith in God. The study revealed faith in God ranked second importance only after their oncologist’s recommendation.[4]

A number of studies show that higher religiosity is associated with wanting more aggressive care at the end of life.   For instance, a study published in the Journal of the American Medical Association showed that “positive religious coping” (as defined by a validated tool called RCOPE) in patients with advanced cancer is associated with receipt of intensive life-prolonging medical care near death.[5] Although the study does not address the reason for this association, it suggests that spirituality may play an important role in patients’ medical decisions.

A second reason health practitioners must pay attention to spirituality is that doing so improves patients’ quality of life. A study of 1610 patients with cancer or HIV found that spiritual well-being (as measured by Functional Assessment of Chronic Illness Therapy Spirituality Scale) was associated with quality of life to the same degree as physical well-being and emotional well-being. The study also found that patients with high levels of spiritual well-being were better able tolerate symptoms such as pain.[6]

If spiritual well-being is associated with a higher quality of life, it stands to reason that supporting patients’ spiritual well-being would improve their quality of life. This was shown to be the case in a study of patients with advanced cancer published in the Journal of Clinical Oncology. It revealed that higher overall spiritual support was positively associated with patient quality of life.[7]

A third reason health practitioners must attend to spirituality is that doing so is part of providing holistic care. Dame Cicely Saunders, who is often considered the founder of the modern hospice and palliative care movement, taught that suffering encompasses the physical, social, psychological, and spiritual parts of a person’s life.[8] Betty Ferrel poignantly speaks to this point when she writes, “The (doctor) who dares to ask about spirituality imparts a vital message to the patient that they are being care for by someone who has not forgotten that a broken patient remains a whole person and that healing transcends survival.”[9]

[1] Lo. B & Tulsky, J. (1999) Discussing Palliative Care with Patients. ACP-ASIM End of Life End-of-Life Care Consensus Panel. Annals of Internal Medicine, 130, 744-749.

[2] Joint Commission on Accreditation of Healthcare Organizations (JAHCO). (1999). Comprehensive accreditation manual for hospitals (CAMH): The official handbook, patient rights, and organization ethics. Update 3

[3] Sloan, R. (2008) Blind Faith: The Unholy Alliance of Religion and Medicine. St. Martin’s Griffin

[4] Silvestri GA, Importance of faith on medical decisions regarding cancer care. J Clin Oncol. 2003 Apr 1;21(7):1379-82.

[5] Phelps, et al. Religious Coping and Use of Intensive Life-Prolonging Care Near Death in Patients with Advanced Cancer, JAMA; 301 (11): 1140-1147

[6] Brady, et al. A Case for Including Spirituality in Quality of Life Measurement in Oncology. Psycho-Oncology. 8: 417-428

[7] Balboni, et al. Religiousness and Spiritual Support Among Advanced Cancer Patients and Associations with End-of-Life Treatment Preferences and Quality of Life. J Clin Oncol. 25 (5): 555-560.

[8] Chi-Keong Ong, Embracing Cicely Saunders’s concept of total pain, BMJ. Sep 10, 2005; 331(7516): 576–577

[9] Ferrell, B. Meeting Spiritual Needs: What Is an Oncologist to Do, J Clin Oncol. 25 (5): 467-468

In his book The Art of Loving, Eric Fromm wrote that “the deepest need of man is to overcome his separateness, to leave the prison of his aloneness.” In the Bible, after forming Adam from the dust of the ground and breathing into his nostrils the breath of life, God declares that something is missing: “It is not good for the man to be alone.”

A number of scientific studies verify that a sense of connection and belonging are crucial for humans to develop, function, and flourish. For instance, The Bucharest Early Intervention Project (BEIP) followed 136 of the tens of thousands of Romanian babies who were abandoned and orphaned as a result of the birth control ban during the regime of Communist dictator Nicolae Ceauşescu. The children were randomized to foster care or the institutional care of an orphanage. Researchers at Harvard University, the University of Maryland and Tulane University have published over 50 papers that show the orphans who remained in institutions have significantly more behavioral and neurological deficits than those who went to families.[1] A recent study used magnetic resonance (MRI) to scan the brains of 74 of the Bucharest children, now ages 8 to 11, and found that brains of children who had remained in institutions had less white matter than orphans who were placed in foster care or children living with their own families.[2]

Family, workplaces, and spiritual communities are some of the places where we form the relationships that give coherence and meaning to our lives. With illness, the infirmities of age, and hospitalizations, people are often removed from these sources of community. For instance, an analysis of the Coping with Cancer Study found a significant decrease in attendance of religious services after individuals received their cancer diagnosis. [3] This suggests patients’ ties to their spiritual communities decreased when support was most needed.

In my own practice, I sometimes see older people suffering in loneliness. Their family members seem too busy with their own lives to visit. Many of their friends have died or are incapacitated. To get out into the world requires driving and getting on the road with younger, faster drivers is an anxiety-provoking ordeal.

We often conceive of health care as consisting of doctors and nurses, medicines and surgeries, hospitals and clinics. But, health or well-being is a holistic concept. It involves, among other things, the state of a person’s mind, body, relationships, finances, and spirituality.  

Accordingly, one of the most important ways a society can nourish the health of its citizens is fostering the creation of relationships and authentic communities. It is especially important to help people at risk for becoming isolated—those with sickness, infirmity, and disabilities—find the human connection we all need.

[1] Bos, Karen J., Fox, N., Zeanah, C.H., & Nelson, C.A. (2009). Effects of early psychosocial deprivation on the development of memory and executive function. Frontiers in Behavioral Neuroscience, 3, 1-7. Nelson, C.A., Furtado, E.A., Fox, N.A., & Zeanah, C.H. (2009). The deprived human brain. American Scientist, 97, 222-229

[2] Sheridan, M. Variation in neural development as a result of exposure to institutionalization early in childhoodProc Natl Acad Sci U S A. Aug 7, 2012; 109(32): 12927–12932.

[3] Balboni, T. Religiousness and Spiritual Support Among Advanced Cancer Patients and Associations With End-of-Life Treatment Preferences and Quality of Life,J Clin Oncol. Feb 10, 2007; 25(5): 555–560.