Religion, spirituality and health: how should Australia's medical professionals respond?

Over the past decade, the number of articles presenting original research on the relationship between spirituality and health has increased sixfold, and now exceeds 1200.1 More recently, several leading medical journals in the United States have published commentaries on this topic.1-6 In essence, these commentaries convey that:

• most original research articles on the topic have found positive associations between increased spirituality and better health outcomes;1,2

• a significant proportion of patients would welcome doctors enquiring about spirituality;1,2

• many US medical schools and some residency training programs include spiritual issues in their curricula;5,6 and

• there needs to be further research into the relationship between spirituality and health, particularly clinical trials of spiritual interventions on health outcomes, and a recognition of the significance spirituality may play in clinical practice.1,2

So far, medical literature in Australia has been relatively silent on the relationship between spirituality and health or its implications for clinical practice.7

Spirituality has been defined as an experiential process whose features include quest for meaning and purpose, transcendence (a sense that being human is more than material existence), connectedness (eg, with others, nature or the divine) and values (eg, justice).2

A religion organises the collective experiences of a group of people into a system of beliefs and practices.2 Religiosity refers to the degree of participation in, or adherence to, the beliefs and practices of a religion.2

The body of research in this area is considerable and diverse.2,7 Associations have been sought between religiosity and the onset of, or recovery from, a broad range of medical conditions. Benefits have also been sought from faith-based therapies. The more rigorous studies have found a positive association between greater religiosity and a better health outcome (Box 1). The evidence is suggestive of a causal association, but is not conclusive.1

Most of the reported studies of spirituality and health have examined adherence to religious beliefs and practices rather than spirituality defined more broadly.4 The commentaries on these studies were published during the 1990s, when Gallup polls showed that religion played a central role in the lives of many US citizens (Box 2).5,6 There appears to have been little change in the results of US Gallup polls since the mid-1930s, suggesting that religion will continue to play a central role in the lives of US citizens for the foreseeable future.9

More than 80% of inpatients in the US have religious needs.10 Although 77% of inpatients consider that, in general, physicians should take more account of these, only about 40% of both inpatients and outpatients want more discussion of their own religious beliefs — unless they are gravely ill.11-13 More religious patients are more likely to want such discussion.11,14 Seventy-two per cent of family practice patients think physicians should refer people with spiritual needs to pastoral workers.14

Although almost all family physicians believe spiritual wellbeing is important for good health and 58% think they should address spiritual concerns, most physicians do so only occasionally or never.11,12,15 Reasons for this include lack of time and training, concerns about projecting personal beliefs onto patients, and uncertainty over managing issues raised.15 Although most family physicians also think patients with spiritual questions should be referred to pastoral workers, again, most do so infrequently.15,16 Not knowing the right person is one reason for this.16

Physicians in the US are generally less religious than their patients.12 The more religious physicians are more likely to enquire about patients' religious beliefs.12

Seventy-two US medical schools have developed courses to teach students how to do spiritual assessments with patients, how to integrate spiritual concerns into therapeutic plans, and when to refer patients to chaplains.5 The inclusion of religious or spiritual instruction in residency training programs is already compulsory for psychiatry and is being discussed for family medicine.5,6,17 Clinicians, educators and researchers in the US have also identified areas for further research (Box 3).1,2,5,18

In the 2001 census, 75% of Australians reported having a religious affiliation (6.7% non-Christian).19 The proportion is higher in rural (86%) and elderly (83%) communities.20 However, the proportion of Australians admitting to a religious affiliation has been declining, particularly in recent times — a fall that cannot be attributed to changes in the wording of the census.21 It is difficult from census data to tell how important religion really is in the lives of Australians.

Box 4 shows the proportion of people in Australia and in the US who believed in God, prayed and attended religious services during the 1980s when surveys in the two countries asked similar questions.9,22 The Australian figures are lower, even though the wording is less exclusive. Moreover, while the proportion of people in the US with a stated belief in God has been constant since the mid-1930s, the proportion of Australians with this belief declined by 12% during the 1960s to 1980s.22 These figures suggest religion did not play the central role in the lives of Australians during the 1980s that it did in the lives of Americans, is probably less important now, and may be even less so in the future.

Reported associations between religiosity and health are therefore not as relevant to Australians as they are to people in the US. Although less religious, Australians may still hold spiritual beliefs. However, our understanding of Australian spirituality and its relationship to health is very limited.23

A proportion of Australian patients may have religious needs and beliefs affecting their care. Non-religious patients may also have spiritual needs, such as for reinforcement of their beliefs about the purpose and meaning of life or for support from another person.2,10 However, knowing neither the prevalence nor the nature of these needs hampers discussion of this question.

One could argue that, in the interests of holistic care, doctors should know whether patients have spiritual needs or beliefs affecting their care and that these are being addressed. If doctors do enquire into their patients' spirituality, they should do so as they would explore other areas of health needing to be discussed sensitively. However, the doctor does not have to be the person who collects this information. Some patients may not want to discuss their own spiritual beliefs with doctors.11,12 For physicians, collecting spiritual information may be time consuming, something for which they are not trained and which they may have difficulty managing, and, because they may project their views onto patients or question their own beliefs, not without risk for their own and their patients' spirituality.3,15 The evidence for doctors discussing spirituality with their patients' being beneficial is also largely indirect or anecdotal.18

It might be better for doctors to refer patients with spiritual questions to a clergy person, other spiritual adviser or social worker.24 However, evidence of patient acceptability and benefit is needed, particularly in view of our current superficial knowledge of Australian spirituality.

While acknowledging our limited understanding of Australian spirituality, it seems reasonable for students to be aware that there is a spiritual aspect to people's lives, including those of Indigenous Australians,25 and that patients may have spiritual needs and beliefs relevant to medical practice. It also seems reasonable for students to know how pastoral workers and counsellors can help identify and address spiritual concerns and of the issues involved in doctors doing so for themselves.

The areas needing research in the US are also very relevant to Australia. However, Australia has important additional research needs of its own (Box 3).