Religion and medicine are twin traditions of healing. Although they have overlapped for most of their history, in the past three hundred years the two traditions have become separate and have often been in competition with one another. At the close of the twentieth century, serious consideration began to be given to reintegrating religion and medicine. In this discussion, a review of the historical connection between these two traditions will be offered. Research that has led to a possible rapprochement will be examined as will the implications for practicing clinicians.

Historical background

There is a long historical tradition that connects religion and medicine. The first hospitals in western civilization for care of the sick in the general population, particularly for those unable to pay for their own care, were built by religious groups. In the fourth century, Basil, the Bishop of Caesarea established one of the earliest hospitals based upon the good Samaritan story in the Bible. This building was resurrected in present-day Turkey among almshouses and leper colonies. For the next thousand years, the church would build and staff most hospitals throughout the western world. Many early physicians, especially those in Europe during the Middle Ages and in the New England colonies of the United States during the seventeenth and eighteenth centuries, were also members of the clergy. In Europe, licenses to practice medicine were in fact controlled by the church and church-sponsored universities.

Similarly, the profession of nursing was to emerge out of the Christian church in the 1600s and 1700s with the Daughters of Charity of St. Vincent de Paul, an order of Catholic sisters devoted to the care of the sick. The Daughters of Charity also established the first nursing profession in the United States in Emmitsville, Maryland, in the early 1800s, modeled after nursing in France. Florence Nightingale (1788–1849), after receiving a "calling" from God, would later receive nurses training from the Daughters of Charity and the Protestant deaconesses (started up by Lutherans in Germany). After the Crimean War, Nightingale applied what she learned to a secular setting. Interestingly, though, up until the early 1900s, most hospitals in Europe and the United States continued to be staffed by nurses who were primarily from religious orders.

Beginning in the fifteenth century, the profession of medicine began to split away from the church, and the state took over the role of administering licenses to practice medicine. That separation would continue to widen until the early 1800s when it was nearly complete. For the last two hundred years, religion and medicine have been divided into separate healing disciplines, with very little overlap and very little communication between the two. However, since about the mid-1990s, especially in the United States, there has been active dialogue about bringing religion and medicine together once again. This movement has been highly controversial and has met with considerable resistance. A growing volume of research showing a connection between religion and health, however, has been breaking down the resistance.

Although the history reviewed above applies primarily to the Christian church, there has been similar interest in health and healing running through nearly all the major world religious traditions, including Judaism, Hinduism, Buddhism, Islam, and Chinese religions. Space does not allow for an adequate discussion of historical connections with medicine for each of these traditions, although resources that do so include Lawrence Sullivan's Healing and Restoring: Health and Medicine in the World's Religious Traditions (1989) and Caring and Curing: Health and Medicine in the Western Religious Traditions (1998) by Ronald Numbers and Darrel Amundsen.

Research on religion and health

The recent trend towards integration of religion and medicine has been stirred primarily by medical research demonstrating intimate and often complex relationships between religion and health. First, many patients indicate that religious beliefs and practices help them to cope with the stress of medical illness. In some areas of the United States, nearly ninety percent of hospitalized patients report that they use religious beliefs to at least a moderate degree to help them to cope. Nearly fifty percent of this group indicate that religion is the most important factor that enables them to cope with medical conditions and the stress they cause. Over one hundred studies have now documented the high prevalence of religious coping among persons with a variety of diseases ranging from diabetes, kidney disease, heart disease, cancer, arthritis, and cystic fibrosis, to more general conditions such as chronic pain.

There is also research demonstrating that persons who are religious end up coping better with physical health problems and disabling conditions. Of nearly one hundred studies conducted during the twentieth century on the relationship between religion and emotional well-being (happiness, life satisfaction, optimism, and hope), nearly eighty percent find that the religious person experiences significantly greater well-being. This is particularly true when populations of medically ill subjects have been studied. The religious are less likely to become depressed or anxious, and if they do develop these mental conditions, they recover more quickly. Suicide is less common among the more religious, as is marital dissatisfaction and divorce, and alcohol and drug use. Nearly 850 studies have now examined these associations, with between two-thirds and three-quarters of these finding that the religious person tends to be healthier and better able to cope with illness.

Of course, a number of studies also report that religion can be associated with worse mental health, more depression, and greater anxiety. This is particularly true for practitioners of religions that are repressive, controlling, and do not emphasize caring for self and others in a responsible way. Religion can be used to justify hatred, aggression, prejudice, and social exclusion. It may induce excessive guilt in situations where guilt is not healthy. Religion may also be used to replace professional psychiatric care for serious mental or emotional problems that require medication and biological therapies. In all of these ways, religion may do a disservice to mental health. In most cases, however, the emotional benefits of religious faith tend to outweigh the negative effects.

There is also a growing volume of research suggesting that religious belief and practices are related to healthier lifestyles, better overall physical health, and longer survival. Studies demonstrate stronger immune functioning among religious persons who are older, who are HIV positive or have AIDS, or have breast cancer. Death rates from coronary artery disease are lower among the more religious, even when health behaviors, diet, and social factors are taken into account. The same applies to mortality from all causes. Since 1990, over a dozen careful studies have demonstrated that the religious person lives longer than the person who is less religiously involved. In these studies, religion is measured by frequency of church attendance, private prayer and scripture study, meditation, and religious coping. Studies have not demonstrated that the broader aspect of religion called spirituality is associated with greater longevity. Spirituality is a broad concept, making it difficult to measure, whereas religious beliefs, practices, and commitment can be more easily assessed and quantified.

Why does religious belief and practice correlate with and predict greater physical health? The answer may lie in the mind-body relationship. There is growing evidence suggesting that emotions influence physiological processes. Psychological stress, anxiety, and depression have been related to impairments in immune functioning, delayed wound healing, and increased risk for cardiovascular morbidity. If religious beliefs and practices reduce emotional stress, counter anxiety, and prevent or facilitate recovery from depression, then religion may help to neutralize the health-impairing effects that these negative emotions have on physical health, and do so through known biological pathways. Mainstream scientists in the field of psychoneuroimmunology are beginning to explore these connections more seriously.

Since about 1980, people have become increasingly disillusioned with medical care that relies solely on high technology and focuses on the biology of disease, while neglecting the care of the whole person. That disillusionment has caused many patients to express a desire to have their spiritual and emotional needs met, as well as their physical needs. Between one-third and two-thirds of patients consistently indicate that they wish their physicians to address religious or spiritual needs in addition to medical needs, particularly when they experience serious medical problems or terminal illness.

Furthermore, there is research indicating that religious and spiritual beliefs impact medical decision making and may even affect compliance with medical treatment, making it essential for physicians to know about these beliefs. Some patients may use religion instead of traditional medical care to treat their illnesses. For example, they may decide to pray for their illnesses and stop taking their medications. There is also research showing that certain types of negative religious beliefs may adversely affect physical health and recovery from medical illness. Patients who feel punished or deserted by God, who question God's power and love, or who feel abandoned by their spiritual community, experience greater mortality and worse mental health outcomes.

Application to medical practice

The growing body of research on religion and health suggests at least the following four applications to medical practice in the West. First, in light of this research, some have argued that physicians should consider taking a spiritual history on patients with serious, terminal, or chronic medical illness. In the United States, only about one in ten physicians consistently addresses spiritual issues by taking a religious history, despite suggestions by a consensus panel of the American College of Physicians and American Society of Internal Medicine that such a history can be obtained by asking a few simple questions. Such questions include the following:

1. Are religious beliefs a sense of comfort or a source of stress for the patient?
2. Is the patient a member of a spiritual community and is this a source of support for the patient?
3. Does the patient have any religious belief that may influence medical decisions or conflict with medical care?
4. There any religious or spiritual needs present that need addressing?

Taking a spiritual history should be done in addition to (not instead of) competently and completely addressing the medical issues for which the patient seeks help from the physician. Thus, a spiritual history is most appropriate when there is more time in the schedule, such as during a new patient evaluation or during a hospital admission workup.

Second, if spiritual needs are identified when the spiritual history is taken, then the research suggests that addressing those needs should improve the health and coping capacity of the patient. This can be done in a couple of ways. The patient can be referred to a trained clergyperson or chaplain. Chaplains in the United States are required to undergo extensive training that prepares them to address such issues in the medical setting. Before a chaplain is certified in the Association of Professional Chaplains, he or she must complete four years of college, three years of divinity school, one to four years of clinical pastoral education, and must take written and oral examinations. Thus, chaplains are skilled professionals with much to offer in this area. Sometimes, however, patients do not wish to speak with a chaplain or clergyperson. In that case, if the patient already has a trusting relationship with the physician, then the physician may need to be prepared to address such issues, even if this involves only listening and showing respect and concern. Nearly two-thirds of the medical schools in the United States have elective or required courses on religion, spirituality, and medicine. In these courses, medical students are trained to take a spiritual history and to address spiritual issues in a sensitive and appropriate manner.

Third, in addition to taking a spiritual history and, if necessary, addressing spiritual issues, the physician may choose to support healthy religious beliefs or practices that the patient finds helpful in coping with illness. Physicians should not prescribe religion for patients who are not interested in religion. There may be benefits, however, in physicians learning about the religious beliefs and practices of their patients and supporting those beliefs that the patient finds helpful and that do not conflict with medical care. Even when religious beliefs conflict with medical care, the patient is likely to profit when the physician tries to understand those beliefs and keep open lines of communication about religious issues with the patient. By way of supporting religious practice, some physicians have decided to pray with their patients. This activity is highly controversial in the medical setting. Conditions for its appropriateness include that:

1. A spiritual history has been taken and the physician knows about the religious background of the patient.
2. Religion is important to the patient and is used in coping.
3. The religious background of the patient and the physician are similar.
4. Either the patient asks the physician to pray (i.e., patient initiates the prayer) or, if the physician initiates it, the physician is certain that the patient would appreciate this activity.
5. The situation calls for prayer (i.e., a difficult, uncontrollable, or stressful situation, severe medical condition, or terminal illness).

Under such circumstances, it may be helpful for a physician and patient to engage in prayer together, enhancing the doctor-patient relationship by increasing trust.

Finally, the research suggests that new social arrangements for medical care may prove beneficial. For example, physicians might develop a communication network with local clergy, both to facilitate a referral base and to allow physicians to assess the community resources that are available to the patient. Religious communities often already provide volunteers to assist with homemaker services, rides to the doctor, respite for exhausted family members caring for the patient, and emotional support to the patient and the patient's family. Religious communities may also monitor the patient to ensure that the medical regimen is being followed and that medical problems are detected early and treatment is obtained promptly. Such a system works especially well when volunteers are appropriately trained and coordinated by a parish or congregational nurse—a registered nurse who is a member of and works professionally as a nurse within the congregation. A parish nurse can coordinate health programs within the congregation that involve screening for high blood pressure, diabetes, depression, and other diseases. A parish nurse can also provide spiritual care, communicate with physicians and nurses within the formal healthcare setting about the health condition of members of the congregation, train and mobilize volunteers within the religious community to meet the needs of sick members, and provide health education to keep healthy members well.

Religion and Western medicine are indeed coming closer and closer together. The research suggests that this is a positive trend—good for the health of patients and for the maintenance of the health of the community. It is also arguably good for the profession of medicine in the West, which is truest to its most basic aims when its practices support the health of the patients in every dimension.

See also MIND-BODY THEORIES; PLACEBO EFFECT; SPIRITUALITY AND HEALTH; SPIRITUALITY AND FAITH HEALING

HAROLD G. KOENIG