However, in a recent issue of the journal, many physicians and clergy with opposing opinions got a chance to voice their opinion.

Dr. Harold G. Koenig, MD, Duke University Medical Center, Durham, North Carolina writes:

I am concerned that Sloan and colleagues (June 22 issue) (1) justify separating religion and spirituality from medical practice by holding up and condemning an extreme position, which is that doctors should prescribe religious activities and counsel patients in spiritual matters. I agree that physicians have no business doing either of the above, but they could take a spiritual history as part of their evaluation of seriously ill patients.

A task force of the American College of Physicians has suggested four simple questions. (2) If a patient indicated that religion was not important to his or her medical care, the physician would not explore further but instead would ask how the person was coping with the illness. If the patient reported using religious beliefs to help cope with illness, then the physician might decide to support those beliefs. Supporting them does not mean recommending or prescribing; it means acknowledging, respecting, and perhaps encouraging the beliefs that the patient finds helpful in relieving suffering. Some religious beliefs that run counter to appropriate medical care may need further exploration with the patient, the patient's minister, or both.

References

1. Sloan RP, Bagiella E, VandeCreek L, et al. Should physicians prescribe religious activities? N Engl J Med 2000;342:1913-6.

2. Lo B, Quill T, Tulsky J. Discussing palliative care with patients. Ann Intern Med 1999;130:744-9.

Dr. David E. Nicklin, MD, University of Pennsylvania, Philadelphia, PA, maintains that it is not unusual for him to inquire about patients' religious or spiritual lives, particularly with patients who are suffering from progressive, incurable, or fatal illness, as well as those struggling with mental anguish or addiction.

It is my practice to ask patients whether spirituality or religion is important in their lives. I then listen, respectfully, to their experience. Some patients report little engagement with these matters, and we go on to other subjects. Many patients talk of the central part God plays in their lives and in their experience of illness. Some describe the comfort and support they obtain from religious and spiritual sources, and I validate this response and encourage them. Some say they have lost touch with religion and spirituality and wish to reconnect with them, and we discuss that. We then go on to the issues of diagnosis and treatment.

I have had many hundreds of such conversations, and not a single patient has responded negatively. The information informs my approach to patients in discussing their illness and their medical choices, sometimes in important ways. I come to know my patients in a deeper way, and they feel seen and heard in ways that matter to them.

Dr. Jacqueline R. Cameron, MD, Northwestern University Medical School, Chicago, IL, writes:

If health is viewed as physical, psychological, social, spiritual, and moral well-being, then it is simply not true that religion and medicine "exist in different domains," as Sloan et al. assert. Human experience and understanding cannot be compartmentalized in this fashion.

Respectful curiosity has long been a hallmark of good physicians. We routinely ask patients about private matters in an effort to screen for depression, domestic violence, and alcoholism. What do we then do with this information? Usually, we refer the patient to a professional with appropriate training and skills. A similar approach to questions about spiritual or religious resources or distress may be very appropriate in many circumstances. (1,2) As always, the patient remains free to decline referrals or refrain from answering questions.

References

1. Holland J. Update: NCCN practice guidelines for the management of psychosocial distress. Oncology 1999; 13(11A): 459-507.

2. Fitchett G. Screening for spiritual risk. Chaplaincy Today 1999; 15:2-12.

According to Dr. Anthony L. Suchman, MD, of Rochester, New York, the original editorial contains several "muddled arguments and contradictions". For example, the authors "imply that because religion is 'personal and private,' it is not appropriate for medical discourse." But Dr. Suchman asks "But what is more personal and private than the experience of illness?"

In addition, "The authors oppose conversations with patients about religion because such conversations are complex and because physicians are not suitably trained to engage in them, yet the authors mention the growing number of medical schools that offer courses in this area," states Dr. Suchman.

Daniel Castro, MD, Lawrence K. Loo, MD, and Debra L. Stottlemyer, MD dispute the claim that only a minority of patients are interested in having doctors discuss spiritual issues with them. They mention a recently published study of theirs that found more than 70% of patients desired prayer with their physician. They also found that women were more interested in prayer than men (83% vs. 63%). They also found that the best indicator of a patient's desire was their response to a questionnaire item stating "Indicate how important spirituality is to you."