Spirituality and medicine have a long, intertwined, history. The very emergence of hospitals in the West arose in part out of the hospitality and care provided by monasteries. Many hospitals have since been founded by religious institutions, and much of medical care throughout the world is still provided by religious hospitals and medical mission efforts. Religious and spiritual life and community provide an important health resource for many people throughout the world. And many people’s medical decisions are shaped by their spiritual and religious beliefs.
And yet, over the past century, we have also seen an increasing division between medicine and spirituality. Certain aspects of medical care have focused more on technology and on disease, than on the person. In many clinical settings, spiritual care is provided very infrequently, even in end-of-life contexts. Most clinicians report having received no training in providing spiritual care. The situation today in the West is very different than it has been throughout much of the past.
During the past three years, several of us at the Human Flourishing Program at Harvard along with colleagues at the Initiative on Health, Religion, and Spirituality, and elsewhere, have been carrying out an extensive systematic review of the literature on spirituality in health and illness. That work was recently published in the Journal of the American Medical Association and we hope that it might help to re-integrate spirituality and medicine.
Our Systematic Review
Our systematic review attempted to survey all literature on spirituality and serious illness, and on spirituality and health outcomes, from January 2000 through April 2022. In total, 8,946 abstracts were reviewed for serious illness, and 6,485 for health outcomes. Strict criteria were used for study inclusion so as to focus on the most rigorous evidence including large sample sizes, validated measures and, for health outcomes, a longitudinal design.
The literature was summarized and synthesized into a number of different potential evidence statements. We then formed a diverse panel of 27 experts to review the individual studies and summaries, to evaluate the strength of the evidence for the various summaries and statements, and to propose, and then quantitatively assess the support for, various possible implications of the research and evidence.
Results and Evidence
Based on the extensive review of the literature, and on evaluation of the evidence, the expert consensus panel concluded that, for serious illness, there was strong empirical support for several findings:
- Spirituality is important for most patients.
- Spiritual needs are common.
- Spiritual care is frequently desired by patients.
- Spiritual needs are infrequently addressed in medical care.
- Spirituality can play a role in medical decision-making.
- Spiritual care is infrequent in medical care.
- Unaddressed spiritual needs are associated with poorer patient quality of life.
- Provision of spiritual care is associated with better patient end-of-life outcomes.
The panel furthermore concluded that, for health outcomes, there was strong evidence that religious service attendance was associated with lower mortality risk; less smoking, alcohol, and drug use; better mental health; better quality of life; fewer subsequent depressive symptoms; and less frequent suicidal behaviors.
For the associations between religious service attendance and health, meta-analyses of longitudinal studies indicated that those frequently attending religious services had a 27 percent lower risk of dying in follow-up and 33 percent lower odds of subsequently becoming depressed. Spirituality or spiritual community thus appeared to be important both in illness and in health.
The expert consensus panel also proposed, and evaluated the empirical support for, various potential implications of the research. The three top-ranked recommendations for serious illness were:
- Incorporate spiritual care into medical care of patients.
- Include spiritual care training for medical students, clinicians, and others on medical teams.
- Ensure access to chaplains for those faced with serious illness.
The three top-ranked recommendations for health outcomes were:
- Have clinicians recognize and consider the beneficial associations between religious/spiritual community and health in providing person-centered care.
- Increase awareness of public health professionals of the evidence on the protective health associations with religious/spiritual community participation.
- Recognize spirituality as a social factor associated with health.
At a practical level, clinicians could take a brief spiritual history with questions like, “Is spirituality or faith important to you in thinking about your health and illness?” and “Do you have, or would you like to have, someone to talk to about spiritual or faith matters?” Such questions can be asked even if patients and clinicians do not share the same set of religious beliefs, and referrals can be made as appropriate. More frequently including chaplains on medical care teams would facilitate such referrals, and would help meet patient needs and patient desires to see these matters addressed.
While the current paper focused on the implications for clinical care, we have discussed elsewhere the possible population health implications of such research as well. Encouragement to participate in community, religious or otherwise, could prove to be a powerful way to improve population health. Such encouragement might also help rebuild community in the wake of the pandemic.
Even in clinical contexts, religious/spiritual community participation could be encouraged for those who already positively self-identify with a particular religious tradition, and participation in other forms of community could be encouraged for those without religious affiliations and beliefs. For those who have had past negative experiences in religious communities, referrals could be made to appropriate specialists who can provide care and support. Taking a spiritual history may help uncover these experiences. These simple practical steps may help re-integrate spirituality and medicine.
Re-Integrating Spirituality and Medicine
Many if not most patients want spiritual care when faced with serious illness. Spiritual community can itself be an important pathway for promoting health. Medicine and spirituality need not be kept separate. The practical steps of taking spiritual histories, providing training in spiritual care, and increasing awareness of community as a health asset could help bring about a re-integration of spirituality and medicine.
Given that spiritual care both is desired and is an important resource, true person-centered care requires attention to these matters. True person-centered care requires the re-integration of spirituality and medicine.