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Several months ago there was an editorial in the prestigious New England
Journal of Medicine (NEJM) entitled "Should
Physicians Prescribe Religious Activities?" The opinion
was co-authored by a physician and a member of the clergy. The editorial
basically was of the opinion that medicine and religion should be
kept as completely separate entities, with physicians not getting
involved in the topic.
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."
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