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SPECIAL COMMUNICATION

Religion, Spirituality, and the Practice of Medicine

Timothy P. Daaleman, DO

Physicians are confronted with new information from the popular media, peer-reviewed journals, and
their patients regarding the association of religious and spiritual factors with health outcomes. Al-
though religion and spirituality have become more visible within health care, there are considerable
ethical issues raised when physicians incorporate these dimensions into their care. Spiritualities are
responsive to patient needs by offering beliefs, stories, and practices that facilitate the creation of a
personally meaningful world, a constructed “reality” in the face of illness, disability, or death. It is
largely through narrative that physicians incorporate into the health care encounter the spiritualities
that are central to their patients’ lived experience of illness and health. (J Am Board Fam Pract 2004;17:
370 – 6.)

“Not a week passes in the practice of the Two current phenomena validate this forecast of
ordinary physician but he is consulted spiritually inclusive health. The first is a burgeon-
about one or more of the deepest prob- ing research interest to explore the process and
lems in metaphysics and religion—not efficacy of religion and spirituality through medical
as a speculative enigma, but as part of models and is best represented by the emerging
human agony.” field of psychoneuroimmunology.6 Researchers at
—Richard C. Cabot, 19181 the University of Pennsylvania have used single
photon emission computed tomography (SPECT)
There is hardly a month that passes in which I’m to image the brains of meditating Buddhists and
not confronted with new information from the ei- Franciscan nuns and have observed localized neural
ther the popular media or peer-reviewed journals activity during this practice.7 The interpretation of
about linkages between religious and spiritual fac- these findings—that religious impulses and mysti-
tors and health-related outcomes. A recent News- cal experiences are reproducible and biologically
week cover story,2 a case conference in JAMA,3 and observable events in the brain— has led to the birth
an original research report from the Journal of the of a new discipline, neurotheology.8 Although
American Board of Family Practice4 represent a grow- much of this research is provocative, the logical
ing awareness of religion and spirituality within progression and implications of this area of inquiry
health care settings in the United States. Indeed, troubles me both as a clinician and as a person of
some forecasters have gone beyond simply recog- faith. Will any experience of God, or what is held
nizing this visibility by projecting the adoption of a to be sacred, be reduced to our gray matter, our
health view that will be more inclusive than our neurons, or ultimately our genetic make-up?
current understanding, a global perspective that One consequence of this overly deterministic
places spiritual factors alongside physical, psycho- orientation, prevalent in biomedical research today,
logical, and social determinants.5 is a largely patient-driven trend to understand and
frame the illness experience in more holistic ways
that are inclusive of religion and spirituality.9 Many
Submitted, revised, 15 June 2004. physicians have customarily considered physical,
From the Department of Family Medicine, University of
North Carolina, Chapel Hill. Address correspondence to psychological, social, and spiritual elements as sep-
Timothy P. Daaleman, DO, Department of Family Medi- arate components constituting the human condi-
cine, University of North Carolina at Chapel Hill, Campus
Box 7595, Manning Drive, Chapel Hill, NC 27599-7595 tion. However there is a growing awareness in
(e-mail: tim_daaleman@med.unc.edu). treating the whole person by viewing health and
This work was supported by the National Institutes of
Health/National Institute on Aging (grant 1K23-AG01033- disease through the integration of mind, body, and
01A1) and the Fetzer Institute. spirit largely within the context of family and com-

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 J Am Board Fam Pract: first published as 10.3122/jabfm.17.5.370 on 8 September 2004. Downloaded from http://www.jabfm.org/ on 15 April 2022 by guest. Protected by copyright.
munity.10 Anthropologists often refer to explana- belief systems; an inner piety or disposition; an
tory models (EMs) as ways in which a patient col- abstract system of ideas; and ritual practices.20 Re-
lectively appraises all these factors to interpret and ligious doctrine and traditions provide a foundation
understand their health and illness.11 Although for understanding the totality of human experience,
there is a rich tradition of incorporating religious primarily for communities of faith. Although spir-
and spiritual perspectives into patient EMs, partic- ituality also has many connotations, theologian
ularly when suffering is involved,12 physician nar- John Shea introduces the term spiritualities as sets of
ratives are becoming more remarkable in a lan- beliefs, stories, and practices that respond to a basic
guage and orientation that touches on the religious human desire to find meaning and purpose in an
and spiritual.13 For example, a prominent AIDS integrated way.21 These beliefs, stories, and prac-
and cancer researcher has authored a best-selling tices may or may not be linked to religious beliefs,
collection of stories with the subtitle, “a spiritual practices, or communities.22 Within clinical set-
exploration of illness.”14 tings, spiritualities are often made manifest in pa-
For some academics, both of these movements tients who seek to make sense of their illness expe-
mark the emergence of a new way to practice med- rience and in caregivers who seek to be attentive to
icine that not only considers, but is actively respon- the needs of the whole person. To further under-
sive to, the needs of body and spirit.15 However, stand the phenomenon of religion and spirituality
many nonphysicians view such a paradigm with in clinical practice, however, it is useful to consider
skepticism and raise considerable ethical questions 3 social perspectives: 2 movements that have legit-
regarding the incorporation of spiritual and reli- imized religion and spirituality in health care; the
gious matters into medical care.16 For the ordinary belief and illness experience of the contemporary
physician like myself, the primary challenge lies not patient; and the physician’s social role within the
only in how I grasp the nuances and complexities of patient-physician encounter.
spirit and belief in my patients and within myself,
but also how we—the patient and I—negotiate the
movements of this unique human dimension across Movements to Legitimacy
health and illness. One illustrative example is a The accelerated interest and recognition of spiri-
69-year-old patient of mine named Mary (her name tuality and religion by health care researchers,
has been changed to protect her confidentiality) educators, providers, and consumers have been
who was newly diagnosed with an aggressive colon building for over 15 years.23 But 2 parallel, pa-
cancer and reported feeling hopeless during a fol- tient-centered movements— end-of-life care and
low-up visit. After my history-taking and physical complementary and alternative medicine— have
examination, I struggled with how to interpret and contributed to the legitimacy of religion and spir-
frame her hopelessness. Is Mary’s disclosure simply ituality in American health care. Both may be seen
a symptom of depression, or is it a concomitant part as an impetus to rehumanize a system of medical
of her illness trajectory?17 Is it representative of a care that has become increasingly impersonal, spir-
larger, as-yet-undisclosed religious or spiritual itually barren, and grounded in technology. The
problem?18 If so, should I probe for further infor- current momentum to improve end-of-life care is
mation? From a treatment standpoint, should I understandably inclusive of spiritual and religious
initiate antidepressant therapy or, if Mary reveals a factors, despite the lack of consistency in how reli-
religious or spiritual issue, recommend an interven- gion and spirituality are addressed in clinical set-
tion that has been clinically proven to be effec- tings.24 For example, a report from the Common-
tive?19 wealth-Cummings project lists patient spiritual and
These are normative and ethical issues for any existential beliefs as an independent modifiable di-
clinician, and they begin to highlight the nuanced mension of the patient’s dying experience,25
distinction between religion and spirituality. I whereas guidelines for palliative care from the In-
would first like to clarify this distinction and to view stitute of Medicine embed a spiritual assessment as
the complex interplay of religion, spirituality, and a measure of the patient’s emotional status.26
clinical practice through a social framework, before Complementary and alternative medicine
considering an ethical paradigm. Religion is asso- (CAM) has also promoted a rapprochement be-
ciated with various connotations: the totality of tween religion, spirituality, and medical practice,

Religion, Spirituality, and Medicine 371

 J Am Board Fam Pract: first published as 10.3122/jabfm.17.5.370 on 8 September 2004. Downloaded from http://www.jabfm.org/ on 15 April 2022 by guest. Protected by copyright.
yet holds a conflicted perspective on the place of to describe spirituality in the context of well-being,
religion and spirituality within its armamentarium. patients in focus group interviews depicted positive
Studies that have examined the prevalence and pat- thinking and self-efficacy beliefs, and agency beliefs
terns of CAM usage vary in their assignment of or their use of power or influence.33 Agency beliefs
alternative spiritual interventions—such as faith are empowering beliefs, viewing people as active
healing and prayer— either as a therapeutic modal- participants constructing their own life course
ity or as a conventional religious or spiritual ritual through the actions that they take.34 Focus group
that is exclusive of CAM. In 1993, a widely publi- participants also outlined an ongoing process of
cized survey on unconventional therapies found finding meaning in the face of illness and of placing
that 25% of respondents acknowledged using their illness experience within a larger life context.
prayer as a medical modality.27 A 5-year follow-up These qualitative data substantiate one conceptual-
study by the same investigators documented an ization of spirituality as a capability to construct an
increase in the use of self-prayer and a prevalence empowering interpretative framework—an explan-
of spiritual healing as a common therapy for anxi- atory model so to speak—through which health,
ety, depression, and lung problems.28 In a recent illness, and life events are viewed. One patient el-
analysis of this data, one third of US adults sur- oquently captured this lattice of meaning and self-
veyed were found to use prayer for health concerns, identity as “that kind of harmonious blending of
both for wellness and for illnesses characterized by the entire.”34
painful or aggravating symptoms, nonspecific diag- Yet if religion and spirituality are tied to indi-
noses, and limited treatment options such as de- vidual systems of empowered meaning, what is the
pression, headaches, and back and/or neck pain.29 link between the lived experience of the patient and
In addition, high levels of perceived helpfulness, or the larger culture that shapes the illness experi-
efficacy, were reported by respondents who used ence?35 Anthony Giddens provides a useful theo-
prayer for their health concerns.29 retical orientation for integrating the individual
perspectives and social currents found in these sur-
veys and narratives. Giddens, a sociologist, posits
A Patient View of Belief, Illness, and Meaning that maintaining self-identity is an ongoing process
The conflicted position of religion and spirituality of selecting and editing our own individual narra-
in end-of-life care and CAM reflects a larger social tives amid a diversity of options and possibilities.36
climate that is ambiguous on the place of religion Self-identity provides us with a sense of control or
and spirituality in the practice of medicine. Popular mastery in day-to-day activities, but when there are
polls are supportive of these CAM findings regard- threats to self-identity and personal meaning, our
ing prayer because most Americans continue to individual biographies are reconfigured and recon-
hold positive attitudes and beliefs about its efficacy structed.37
in healing, although they remain uncertain about Returning to Mary, the diagnosis and impending
religion and spirituality in the medical encounter. A treatment of cancer have already confronted her
USA Weekend poll found that 79% of respondents with the specter of a chronic or life-limiting illness,
believe that spiritual faith can help people recover a functional limitation, or a compromised quality of
from disease, but only 56% said that their faith had life, all threats to her self-identity. Within this
actually helped in their recovery.30 A more recent context, spirituality may be conceptualized as how
multicenter survey found that a only a minority of she begins to integrate her illness experience within
primary care outpatients preferred that physicians her larger life course and how well this meaning
address religion and spirituality during routine making empowers her to live her life. Yet she ar-
office visits.32 The study also found that context rives at this point with a lifetime of accumulated
was an important factor because patients desired beliefs, stories, and practices, her background spiri-
greater physician involvement with their spiritual tualities.21 Many of these spiritualities will be linked
and religious concerns when the severity of their with an identified religious or faith tradition; some
illness increased (ie, when hospitalized or near will not. But all Mary’s background spiritualities
death).32 are responsive to the current threat to self by of-
Studies on a more individual level clarify some of fering beliefs, stories, and practices that provide a
the inconsistencies in these findings. When asked template for the ongoing creation of a personally

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 J Am Board Fam Pract: first published as 10.3122/jabfm.17.5.370 on 8 September 2004. Downloaded from http://www.jabfm.org/ on 15 April 2022 by guest. Protected by copyright.
meaningful world, a constructed empowered “real- example, provide an important ethical foundation
ity” in the face of her current illness. Mary’s con- for decision making in many areas, such as physi-
structed world will be manifested by her beliefs, cian-assisted suicide and end-of-life care.42
stories, and practices that have been transformed by Sustained clinical narratives that are cocreated
this experience, her foreground spiritualities.21 More by both patient and physician spiritualities may be
importantly, her constructed sense of self is contin- therapeutic for physicians as well. Patient care not
gent on the actions and interactions she maintains only engages us as experts but also presents the
in a larger social world, with her family and friends, concurrent challenge of maintaining our own per-
and with me as her physician.38 sonally meaningful world. As physicians, our life’s
work confronts and sometimes threatens our sense
of self through the disability, serious illness, or
The Physician’s Social Role death of those we care for. Yet the spiritualities
As a physician, I occupy the role of expert within offered through patient narratives can contribute to
the patient-physician relationship because of my the ongoing construction of our own self-identities
specialized knowledge and skill.37 Beyond the tech- by presenting and affirming the human condition
nical task of diagnosing and treating disease, I am in its entirety. For some physicians, spiritualities
also responsible for being attentive to my patients’ may be inclusive of practices that are common to
social milieu and for providing information within patients, such as prayer, reflection and self-aware-
the context of their illness experience.39 It is ness.43 For others, spiritualities may arise as philo-
through my clinical impressions and in the recom- sophical or religious belief systems; beliefs that may
mendation of selected therapeutic interventions be held or shared with their patients, beliefs that
that I convey cultural scripts and suggest illness provide a foundation of purpose for our work.44
trajectories to patients and family members. This is However, for all physicians, spiritualities that are
a unique social role for physicians. Mary’s disclo- brought forth by patient stories, and are woven into
sure of hopelessness, for example, may be framed in our own ongoing narratives, are responsive to a
a traditional medical model by my assessment of a basic human desire of finding meaning in an inte-
major depressive episode and consultation with a grated way.
psychiatrist. However, if Mary’s hopelessness re-
sults in her decision to forego aggressive treatment,
I may view her choice of care as the beginning of a An Ethical Paradigm of Spirituality
more active dying process and possibly recommend Spiritualities—those beliefs, practices, and stories
hospice care. that respond to a shared human need for mean-
There is inherent power that every physician ing—are generated from our social actions and in-
holds by virtue of possessing a specialized knowl- teractions. The lived social worlds of patient and
edge of diagnosis, prognosis, and treatment.40 Im- physician intersect during the clinical encounter,
plicitly or explicitly, we wield power through our the central activity within medicine that defines the
frameworks and in the selection of cultural scripts moral obligations of physicians.45 Both patient and
and illness trajectories that we present to patients. physician arrive at this moment with a lived history
But in every clinical context, patients may choose to that is grounded in the social and cultural, and
either incorporate or discard these scripts as they these frameworks—which are external to medi-
construct or reconstruct their self-identities.37 In cine—include moral imperatives, because they
any event, the resultant clinical narratives are sto- specify what ought to be done to achieve health and
ries of a therapeutic activity facilitated and cocre- healing.46 The ethical challenge of intersecting pa-
ated by the spiritualities of both patient and physi- tient and physician spiritualities lies in how both
cian over time. Larger cultural and social factors negotiate these movements across health and ill-
within and outside of these clinical encounters are ness.
also embedded within this activity.41 Factors such At the onset, any paradigm must be congruent
as race/ethnicity, social support, education, gender, with ethical principles that guide other aspects of
and religion may be key parts of the scaffolding in clinical practice.47,48 However the concept of
the construction of a meaningful world in face of power—the empowering agency beliefs of the pa-
illness, disability, or death. Religious traditions, for tient and the power that physicians wield through

Religion, Spirituality, and Medicine 373

 J Am Board Fam Pract: first published as 10.3122/jabfm.17.5.370 on 8 September 2004. Downloaded from http://www.jabfm.org/ on 15 April 2022 by guest. Protected by copyright.
illness scripts and trajectories—is basic to under- negotiation and persuasion and with concern for
standing and ethically considering spirituality in the patient’s vulnerability.50
clinical practice. Howard Brody suggests several
guidelines for the ethical use of power within the
Final Comments
clinical encounter.40 First, physician and patient
Brody closes his recommendations with a clinical
should use all their power to effect a good patient
dictum that physicians should regard the physician-
outcome that is determined by the patient’s defini-
patient relationship as a primary therapeutic tool.40
tion of the presenting problem, and by a contextual
This therapeutic tool holds true for both for phy-
understanding of the patient’s life course.40 In dis-
sicians and patients. It is through narrative that
cussing Mary’s diagnosis and treatment, I have be-
physicians begin to palpate the spiritualities—the
come aware that she sees cancer as more threaten-
stories, beliefs, and practices—that reside outside of
ing to her ability to work and remain productive—a medicine but are central to our patients and our
source of her agency beliefs—than as a death own lived experience of illness and health. In the
threat. This helps us both to define the primary context of our ongoing relationships with patients,
good outcome at this time. spiritualities empower us to negotiate this terrain
Brody goes on to recommend that physicians by facilitating and maintaining an entree into the
should share their power by informing the patient patient world. This normative and moral activity of
about the nature and treatment of the disease.40 I spirituality lays the foundation for a common
would go further and extend this exchange by in- ground of a greater and sustained therapeutic ac-
cluding the physician’s contextual interpretation of tivity for both patient and physician. And it is here
illness as templates and trajectories during the dis- where the purpose and goals of medicine are fash-
closure. Physician power is shared when more than ioned and refashioned.46
one template is introduced, because patients are But this common ground of patient and physi-
free to incorporate or discard any proposed tem- cian is a place filled with a creative, transformative
plate. Mary’s disclosure of hopelessness is illustra- tension. As Mary and I journey on together, we
tive. After reflecting back her comment, I was have no idea how our story will unfold. However, I
aware that she had been treated for depression in do know that I have already been changed in some
the past and acknowledged that hopelessness was way and sense that she has been as well. This
sometimes an indication of depression; one tem- tension reinforces for me that the practice of med-
plate was offered. Another template focused on my icine is a basic social enterprise, a human interac-
recollection that Mary had been divorced for some tion in which meaningful stories of health and ill-
time and had never mentioned her family during ness are cocreated by patient and physician. It is a
any clinic visit. I reflected that the diagnosis of tension where I dwell as an “ordinary physician,”
cancer can leave us feeling alone and hopeless, the nexus between the scientist who seeks to ad-
often generating a need for reconciliation with ei- vance the human condition and the clinician who
ther ourselves, with those close to us, or sometimes shares the lived experience of the patient. And it is
with God. a wondrous tension that recognizes the limits of
Patient agency beliefs may be inclusive of spe- human medicine but the limitless human spirit.
cific tenets of faith or practices from religious tra-
ditions. A belief in healing or prayer comes imme-
I thank G. Gayle Stephens, MD, and an anonymous reviewer for
diately to mind. Brody suggests that physicians their comments on earlier versions of this manuscript.
should be supportive of these sources of patient
empowerment, as long as they are consistent with a
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