Mixing Religion and Health: Is it Good Science?

As the millennium approaches, spirituality is playing a more prominent role in medical practice. Many Americans believe that religious activity can promote health, and physicians report an increasing number of patients requesting at least discussion of religion in their treatment. In response, about 30 medical schools now offer courses in religion and spirituality.1 Support comes from other sectors too. "The Senate recently appropriated $50 million to set up five major centers to study mind-body medicine around the country, including any religious connection," says Harold Koenig, associate professor of psychiatry and assistant professor of internal medicine, Center for the Study of Religion, Spirituality, and Health at the Duke University Medical Center in Durham, N.C. And April 11-13, the University of Arizona in Tucson will host an international conference, "Spirituality, Healing and Health: A Transformative Vision." But public interest, new medical school curricula, increased funding, and even published papers do not necessarily add up to rigorous scientific evidence. And so a team led by Richard Sloan, associate professor in the department of psychiatry and director of behavioral medicine at Columbia-Presbyterian Hospital in New York, decided to investigate. Their findings, published in a recent issue of The Lancet,2 touched a nerve that landed Sloan and Koenig on the Today show on Feb. 23. Concludes Sloan, "most of the studies are, quite simply, bad science. It is critically important that claims of religious activity be subjected to the same rigorous inquiry as any other medical claims. There is no compelling evidence that religious activities promote health." The Lancet paper did not deny a causal connection between religiosity and health; it merely pointed out flaws in investigations. But John Root Wolpe, faculty associate in the Center for Bioethics at the University of Pennsylvania in Philadelphia, disagrees with Sloan's method of criticizing individual papers. "There's no such thing as the perfect study ...; each individual study has flaws." It's the preponderance of evidence that's important, he says. Certainly, the Lancet paper was not a meta-analysis--the gold-standard study-of-studies often used to gain a sense of consensus--perhaps because published investigations of the health-religion link are so varied as to transcend even an apples-and-oranges comparison. "It's a real mess, more a fruit salad of information. A meta-analysis is only as good as the studies it analyzes," says Sloan. Measures of religious observance, health parameters considered, and variables controlled for vary to such a degree as to make comparisons nearly meaningless, Sloan maintains. It's easy to see why the public thinks the religion link is firmly grounded in medical science. Consider a recent report from Koenig's group on the relationship between religious activities and blood pressure.3 The huge effort analyzed data from nearly 4,000 adults over three periods since 1986, with many controls. Yet the outcome was only a 1 to 4 millimeter of mercury difference in blood pressure between those who attended religious services at least weekly and those who didn't, a figure Sloan calls "clinically meaningless." (Interestingly, those who reported watching religious TV or listening to religious radio experienced elevated blood pressure!) Still, the report's final paragraph extrapolated those modest millimeters into a potential populationwide decrease in cardiovascular disease incidence of 10 to 20 percent. Koenig's interpretation may not be surprising given that the Radnor, Pa.-based John Templeton Foundation helps fund his research. The foundation hopes that "by promoting collaboration and clinical research into the relationship between spirituality and health and documenting the positive medical aspects of spiritual practice, [it can] contribute to the reintegration of faith into modern life." Tearing apart the complex web of threads that enmesh religious belief and physical well-being may not be readily amenable to full scientific scrutiny. At a minimum, the various factors probably call for an exhaustive epidemiological approach. Yet despite a claim that "research on religious factors in health is as sophisticated as any other growth area within epidemiology,"1 Robert Haley, director of the division of epidemiology at the University of Texas Southwestern Medical Center in Dallas, says he is "not aware of really sophisticated epidemiological studies in the mainline medical literature" on the subject. Koenig and Sloan agree that one of the best studies attempted to identify the confounding factors that impede many investigations, such as smoking, alcohol use, and exercise. In this study, researchers at the Human Population Laboratory in Berkeley, Calif., followed 5,286 people over 28 years and found that those who were regulars at religious services, particularly women, had statistically significant lower rates of mortality.4 These individuals, when questioned at the study's conclusion, tended to report that they smoked less, exercised more, had more social contacts, and were more likely to have remained married than those who attended services rarely or not at all. The researchers call these other factors "intervening variables that lie on the causal pathway between attendance and mortality." Intervening variables probably underlie the relationship between a variety of emotional and behavioral factors and physical health. Even the well-established placebo effect illustrates the connection between expectation or peace of mind and at least the perception of improved health.5,6 Anything that makes people more relaxed, confident, and optimistic could produce healthful results, or at least a transient respite from suffering, as Robin Williams in the movie Patch Adams showed when he stuck a rubber bulb on his nose and cheered young cancer patients. Backing up the observation that good vibes and good health seem to go hand in hand is an extensive record in the psychology literature, and a section on optimism and health on the American Psychological Association's home page (www.apa.org). Studies linking optimism to signs of improved health are marvelously eclectic. Among the most clever was the dissertation project of Suzanne Segerstrom, now an assistant professor of psychology at the University of Kentucky in Lexington. She probed a highly stressful situation--the first semester of law school--and showed that those with an optimistic outlook also had better moods, higher T-cell counts, and more murderous natural killer cells.7 "I did not choose this group for the opportunity to stick lawyers with needles," says Segerstrom, who decided on law students after talking to friends, reading Scott Turow novels, and searching the literature on stress. But unlike Koenig's finding that incremental increases in blood pressure were of clinical import, Segerstrom says that the slight elevations in immune response she detected do not necessarily translate into significant differences in health. It was probably inevitable that someone would link optimism to religiosity. Martin Seligman, professor of psychology at the University of Pennsylvania, did so, discovering that fundamentalists tend to be more optimistic compared to other religious groups.8 Researchers have scrutinized the reverse link, between depression and poor health, since 1937. After correcting for a variety of risk factors such as smoking, several studies associated depression with cardiovascular disease and mortality.9 A recent study assessing data from the Johns Hopkins Precursors Study, which started in 1948, did not pinpoint precise mechanisms connecting depression with a sick heart, but suggested that the altered neurotransmitter levels, blood chemistry, and platelet function seen in depression also may explain cardiac pathology.10 A study correlating higher risk of cancer with depression hypothesized that several factors including central nervous system dysfunction, adrenal corticosteroid secretion, and compromised immune system surveillance may underlie the link.11 Even the nonreligious and perpetually pessimistic among us have recourse to calm ourselves in a possibly therapeutic way. Records of pets being used to treat people date back to the 18th century, and today formal programs and how-to books recommend Rover as a cotherapist in mental institutions and nursing homes.12 One study links pets to lower mortality rate in cardiac patients.13 Even iguanas and guppies can be man's best friend. But why stop with pets? At St. Patrick Hospital in Missoula, Mont., harpists comfort the terminally ill, lessening the need for pain medication, as reported on Dateline NBC. It makes great TV and it's wonderful if true, but we haven't seen controlled studies published in mainline medical journals that confirm the link. The Columbia researchers opened the spirituality can of worms because they feared the consequences of physicians advocating religion in medicine--or the flip side, somehow implying that an ill person hasn't been devout enough. Sloan compares the situation to marriage, which is widely regarded as having health benefits. "The evidence is very solid. But we would never expect a doctor to say, 'there is compelling evidence that marriage is beneficial to health--my advice is to get married.' That would be regarded as an outrageous intrusion. It is even more so for religion than marriage." To an extent, the Lancet paper addressed a concern that certain religious groups or overzealous physicians injecting spirituality into medicine have a hidden agenda, much the way that creationists have an agenda in their war against evolution. The Templeton Foundation admits as much. But is seeking "positive medical aspects of spiritual practice" good science? Ethicist Wolpe sees little danger, saying that the Columbia researchers raised straw men that are "far out from the real ethical issues .... I have never once heard anyone advocate that a patient should be encouraged to become more religious or to convert in order to improve [his or her] health." Instead, Wolpe sees nothing wrong with physicians asking about religious practices if the information is used to the patient's advantage. Haley, who is also a practicing internist, thinks "it's not a doctor's position to produce death bed conversions," but he "always tries to perceive what his patients' religious views are," because they may be important in treatment. "I use [religious] information just to know how to talk to patients," such as about death, he adds. And Sloan and Koenig, despite their vocal differences on the quality of research in the area, agree that a doctor shouldn't tell a patient that religion can heal, but he should be receptive if a patient wishes to discuss how belief helps in coping with illness. The interest in spirituality and healing suggests that perhaps we should assess it in the broader context of alternative or unconventional medicine, which is booming. A 1993 study estimated that people made 425 million visits to unconventional therapy providers three years earlier, which if accurate far exceeded the 380 million visits made to primary care physicians.14 The number was surely much higher in 1998 when The New England Journal of Medicine devoted the better part of an issue to the subject.15 When people feel freer to choose one from column A and one from column B, it's not surprising that religion, pets, and music are on today's medical menu. Barry A. Palevitz (palevitz@botany.dogwood.uga.edu) and Ricki Lewis (rickilewis@nasw.org) are contributing editors for The Scientist. J.S. Levin et al., "Religion and spirituality in medicine: research and education," The Journal of the American Medical Association, 278:792-3, 1997. R.P. Sloan et al., "Religion, spirituality, and medicine," The Lancet, 353:664-7, Feb. 20, 1999. H.G. Koenig et al., "The relationship between religious activities and blood pressure in older adults," International Journal of Psychiatry in Medicine, 28[2]:189-213, 1998. W.J. Strawbridge et al., "Frequent attendance at religious services and mortality over 28 years," The American Journal of Public Health, 87:957-61, 1997. S. Blakeslee, "Placebos prove so powerful even experts are surprised," The New York Times, Oct. 13, 1998, page F1. A.K. Shapiro and E. Shapiro, The Powerful Placebo, Johns Hopkins University Press, Baltimore, 1997. S.C. Segerstrom et al., "Optimism is associated with mood, coping, and immune change in response to stress," Journal of Personality and Social Psychology, 74:1646-55, June 1998. S. Sethi and M.E.P. Seligman, "Optimism and fundamentalism," Psychological Science, 4:256-9, 1993. A.H. Glassman and P.A. Shapiro, "Depression and the course of coronary artery disease," American Journal of Psychiatry, 155:4-11, January 1998. D.E. Ford et al., "Depression is a risk factor for coronary artery disease in men," Archives of Internal Medicine, 158:1422-6, July 13, 1998. B.W. Penninx et al., "Chronically depressed mood and cancer risk in older persons," The Journal of the National Cancer Institute, 90:1888-93, Dec. 16, 1998. M.R. Burch, Volunteering With Your Pet--How to Get Involved in Animal-Assisted Therapy with Any Kind of Pet, New York, Simon and Schuster/Macmillan, 1996. A. Beck, A. Katcher, Between Pets and People-- The Importance of Animal Companionship, West Lafayette, Ind., Purdue University Press, 1996. D.M. Eisenberg et al., "Unconventional medicine in the United States," New England Journal of Medicine, 328:246-52, 1993. M. Angell, J.P. Kassirer, "Alternative medicine--the risks of untested and unregulated remedies," N. Engl. J. Med., 339:839-41, Sept. 7, 1998.

Mixing Religion and Health: Is it Good Science?

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