In this issue of the Journal, Peach examines whether the medical profession in Australia ought to consider patients' religion or spirituality in clinical practice (page 86).1 There is much that Peach writes which I wholeheartedly support. This includes the important role that clergy play in medical settings, the need for further research on the health benefits (and risks) of spirituality in Australian patients, and the need to better understand the costs and benefits of Australian physicians making spiritual inquiries. However, on four points we disagree:

• Australians are not as religious as Americans and therefore religion is less important for Australian patients;

• although religion appears associated with health in the United States, there is little evidence for this in secularised Australia;

• assessing spirituality should probably be deferred to clergy or social workers; and

• until more is known, including spirituality in medical practice (in addition to addressing it in Australian medical schools) would be premature.

Although Australians may be less religious than North Americans, the difference is not that great. Belief in God has decreased in Australia, but it has not gone away. In 1948, 95% believed in God; by 1975, the figure was 80%.2 In 1998, 74% believed in God, a higher spirit or life force,3 and according to the 1996 census only 0.05% of Australians are avowed atheists. When physical or emotional illness strikes, spiritual issues become even more important, as issues of meaning and purpose become relevant. This is particularly true for older adults with chronic illness, a population that will increase as Australians older than 65 years increase from 2.4 million people in 2001 to a projected 5.4 million in 2031.4

Even among younger patients, spiritual practices assume substantial importance. Consider a study of 108 patients (mean age 38 years) from medical practices in Sydney, in which researchers examined patients' experiences concerning the efficacy of 25 coping behaviours.5 Forty-one per cent of subjects indicated they would increase prayer in response to stress, 56% said prayer was helpful and, overall, prayer was ranked seventh in effectiveness, ahead of 18 other traditional coping behaviours, such as discussing the problem, seeking advice, spending time with friends, or socialising. Similar findings emerge among psychiatric patients. A study of 79 psychiatric patients at Broken Hill Base Hospital in New South Wales found that 79% rated spirituality as very important, 82% thought their therapist should be aware of their spiritual beliefs and needs, and 67% indicated that spirituality helped them cope with psychological pain.6 Thus, at least preliminary research suggests spiritual needs are not uncommon among Australian patients.

Is religion related to better health in Australia? Although research is less plentiful than in the US, it is not entirely absent.7 Australian studies have found greater marital stability, less alcohol and illicit drug use, lower rates of and more negative attitudes toward suicide, less anxiety and depression, and greater altruism among the religious. Religiosity has also been associated with less cigarette smoking, more conservative sexual practices (reducing risk of sexually transmitted diseases), lower cortisol and catecholamine levels (for meditators), lower blood pressure, lower cholesterol, longer survival (Seventh Day Adventists), and even lower risk for colon cancer.8 Such findings are similar to those in the US,7 and, although more research is needed, these findings cannot be ignored.

Because religion relates to health, and spiritual issues are important to many sick patients, deferring assessment of all such issues to clergy or social workers is probably unwise. Although physicians are not trained in this area, brief evaluation and orchestration of resources does not require great skills beyond what physicians already possess. Insufficient time is a problem, but it is not the main reason why physicians don't address spiritual issues. Rather, it is lack of comfort.9 Not knowing why or how to address such issues and feeling worried about imposing their beliefs on patients, not surprisingly they avoid the topic. Nevertheless, a brief spiritual history gathers information that is medically relevant and necessary to practice whole-person medicine.10 Are religious beliefs a source of comfort or stress in coping with illness? Does the patient have religious beliefs that could interfere or conflict with medical treatments? How might religious beliefs influence medical decision-making during serious or terminal illness? Is the patient part of a supportive faith community that can monitor and ensure compliance?

Physicians also need to know their limits. If complex spiritual issues come up during assessment, then referral to trained clergy is appropriate and necessary. Physicians should not offer spiritual advice or counselling, or try to solve a patient's spiritual dilemmas. A patient who is not religious or does not wish to talk about such issues should not be pressed. Such inquiries must always be patient-centred, guided by the patient's wishes and religiosity, not the physician's. Nevertheless, taking a moment to listen, validate concerns, and mobilise spiritual resources are actions that physicians can do. Likewise, if the patient is a member of a faith community, then working with a parish nurse after discharge may ensure successful transition from hospital or medical office to home and community life.11

Exposing medical students in Australia to the role that religion plays in coping with illness and the research connecting religion and health should not be delayed. There is ample evidence to support some cautious first steps.12 Certainly, as Peach suggests, ongoing research is necessary. Nevertheless, religion is a powerful factor that can influence health, wellbeing, and medical decisions for better or worse. It should not be ignored or neglected by physicians.