Duke University Alumni Magazine


Photo: Ian Southerland

"Spiritual questions are too important to life and death to ignore any longer. Medicine has come to the slow realization that we really do have to treat the whole person."

n matters of convenience and necessity, we tend to be accustomed to, and accepting of, the pervasive power of technology. That's certainly the case for medical care. In contemporary culture, technology is the great healer, and when it comes to medical care, our faith in technology may trump our faith in faith.

But thinking has shifted a bit, perhaps shifted back to earlier notions, since religious expression was long considered basic to care for the sick and dying. Duke now has an Institute on Care at the End of Life, along with a Health and Nursing Ministries program. A third program, run by the Center for the Study of Religion, Spirituality, and Health, probes whether religious faith helps us live longer, healthier lives, and explores whether faith can heal illness. Why these programs, and why now? According to Harvey Cohen, chief of geriatrics and director of Duke's Center for the Study of Aging and Human Development, the answer is profoundly simple. "Spiritual questions are too important to life and death to ignore any longer. Medicine has come to the slow realization that we really do have to treat the whole person."

Photo: Ian Southerland

Treating the whole person, then, would include religion as part of a patient treatment plan. But this is an idea that raises many questions. Can we--or should we--use religious faith to heal or even prevent illness? In the context of twenty-first-century medicine, thinking about religious faith in such a way may seem archaic, even ignorant. Many physicians who are willing to accept discussions of faith at bedside would balk at using faith for treatment and prevention. That kind of thinking is for shamans and faith healers, they argue, and should be kept far away from the fluorescent-lit linoleum of modern hospitals. But Shelly Cole would say those naysayers are wrong.

At thirty-five, Cole had suffered mental illness most of her life. She was sexually abused as a child, and growing up, one of her prayers had been, "Lord, just let me go to sleep and die." She married, then divorced an abusive man who often threatened her with a .38 revolver. Long bouts of depression prevented her from finishing a music degree at the University of North Carolina at Chapel Hill. In 1995, she attempted suicide and was hospitalized for a year. Doctors from Duke Medical Center prescribed increasing doses of antidepressant medication, but Cole made only marginal progress.

Finally, after ten months, Cole was granted a weekend pass from the hospital to attend a religious retreat with her sister. That weekend began a religious conversion that Cole says gave her insight into the meaning of her lifelong pain. She became convinced that God had a plan for her to help others and, with a newfound hope and sense of purpose, her symptoms seemed to evaporate in a short time. Not long after her conversion, doctors released her from the hospital. She stopped taking antidepressants "cold turkey" and began substituting long, meditative prayer and Scripture readings for the drugs. She experienced no withdrawal and no relapse. She joined a church and, in 1998, won its annual award for most active community volunteer. Today, Cole is convinced her chronic illness has been vanquished by faith.

Did faith heal Shelly Cole? Psychiatrist Harold Koenig says it's definitely possible. Koenig has studied patients like Cole for nearly two decades, trying to determine the impact of religious life on physical and emotional health. He recently published his findings in the book The Healing Power of Faith: Science Explores Medicine's Last Great Frontier (Simon & Schuster, 1999).

Koenig came to Duke in 1986 after training in family medicine at the University of Missouri. While at Missouri, he frequently encountered patients whose strong religious faith seemed to affect them in surprising ways: An alcoholic he thought was beyond salvaging relied on faith to recover; an elderly couple enmeshed in marital difficulties found spiritual joy and closeness despite their problems. His conversations with such patients led him to renew his own commitment to God in his thirties. "I became more and more religious as I was listening to what people were saying. It made me think, 'This is something real.' "

As a medical researcher, he wanted to explain the phenomenon in rigorous scientific terms. That quest became what he now considers his life's work. But well into the mid-1980s, there was still a high wall between science and religion, and Koenig says he was labeled as "something of a freak" for his research. Psychiatry in particular remained heavily influenced by Freud's view that religion was a crutch for people who couldn't deal with the reality of the world; or as psychologist Albert Ellis put it, "religious belief is akin to an emotional disturbance...a disease infested with 'shoulds' and 'oughts' and admonitions of guilt." Some colleagues told Koenig he was committing professional suicide. He saw himself merely asking simple, practical questions.

"I just wanted to bring to light what I thought was a truth," says Koenig. "How could you be a family doctor and not know what gave a patient's life meaning and purpose?"

"In those days, residents and med students were taught that it was unethical to discuss religion with patients," says David Larson, president of the National Institute for Healthcare Research, a nonprofit group dedicated to investigating the religion-health connection. "There is still some nervousness even now, so this field needed a solid research. Harold has really set the standard in terms of quality and focus."

Other prominent physician-researchers have studied spirituality's effect on health, including Herbert Benson of Harvard's Mind-Body Medical Institute and Larry Dossey, the author of Healing Words, a book on the power of prayer. Benson focuses on the body's physiological response to meditation and spiritual calm. Dossey invokes both Western and Eastern religion in his survey of prayer's role in healing. But under Koenig's direction, the Duke Center for the Study of Religion, Spirituality, and Health became the first to focus on the impact of traditional religious faith and practice.

In the last fifteen years, Koenig has led more than twenty-five research projects and published scores of articles on the effects of religious life on health. During that time, numerous other investigators have hopped on the holy bandwagon. Only 7 percent of nearly 300 studies in the past fifteen years suggest evidence that religious practices harm health, mostly in cases where "faith-healing" congregations resist medical care. More than 75 percent of the mounting body of research suggests that religion positively influences health. According to these groundbreaking findings, people of faith--those who regularly attend church services, pray, and read scripture--are:

  • More likely to have lower blood pressure and stronger immune systems;

  • Hospitalized much less often than non-religious people;

  • Less likely to suffer depression from stressful life events, and if they do, are more likely to recover;

  • More likely to live longer and be physically healthier into later life, in part because religious people tend to avoid unhealthy habits like alcohol and drug abuse or risky sexual behavior.

Faith also seems to protect the elderly from cardiovascular disease and cancer. In terms of survival and longevity, Koenig says, "Religion may be as significant as not smoking."

Though the findings are impressive, critics say it is still too early to conclude that faith is a medical elixir. "These types of studies do not demonstrate an absolute causal relationship," says Dan Blazer, dean of medical education at Duke. "They really just give us correlations that provide good leads."

Skeptics argue that faith-health research studies are littered with too many "confounds," such factors as age, sex, socioeconomic status, education, and genetic differences that are never completely controlled for, despite the best experimental design. Keith Meador admires Koenig as a colleague, but criticizes his research for ignoring subtle questions of context. "Take, for example, the form question: 'Is religion important to you?' " says Meador, a psychiatry professor in the medical school and a professor of pastoral theology and medicine at the Duke Divinity School. "When a person in a cross-sectional survey says, 'Yes, religion is important to me,' how do you interpret that?" Meador proposes that such answers are meaningless without knowledge of a subject's history and environmental context. "Research is interpretation-laden. That's always true, but it becomes even more important when you start to look at issues like religion."

Koenig says such concerns are absolutely valid, and he takes them seriously. "I hope my own faith, if anything, spurs me to be as scrupulous and rigorous as possible." His research team recently completed a systematic review of more than 1,100 studies conducted by researchers at different institutions on varied populations. "The vast majority of these studies show a relationship between greater religious involvement and better health," notes Koenig. "Many are not perfect because of the difficulty of studying this topic...[but] there are relatively few showing no relationship, and virtually no studies showing a significant negative relationship between religion and health."

The notion that religious people might live healthier or longer lives begs the question: What ingredients of religious faith are necessary to provide such benefits? One answer is that truly religious people are more likely to avoid such obvious health risks as drug abuse or promiscuous sexual behavior, but research also indicates that sincerely religious people tend to view events in their lives as part of a pattern--not as accidents. As a result, they are more likely to imbue events with meaning. They are also more likely to see God as benevolent, as a being who cares what happens to them, even if bad things happen to good people all the time. Israeli psychiatrist Aaron Antonovsky, a prominent researcher into the effects of "meaning-making" on health, says such a mental template applied to everyday life results in a protective "sense of coherence" for believers, a belief that life has reason and purpose to it.

Others suspect that the benefits of religion largely boil down to friendships and social support, another factor that has been shown to improve mental and physical health. But as Koenig notes in his recent book, the research suggests that even when comparing religious churchgoers to people who gather for secular reasons, like weekly support groups or Monday Night Football, religious groups are healthier. Koenig also believes there is a crucial difference in the type of social support among religious groups. "When it's good, it's a social support that is sustained, and not 'you scratch my back, I'll scratch yours,' the way many social encounters are in secular life," he says. "It's a little closer to an unconditional love--not expecting something in return."

One thing seems certain: Faith must be real to have an impact (again, a tricky concept to measure). Although more than 95 percent of Americans believe in God, according to a 1996 Gallup poll, research indicates that merely paying intellectual lip service to God is not enough to promote health. Faith must be relevant to daily life and affect subsequent behavior. Thus, Koenig says, curling up on the couch to watch Touched by an Angel won't help a person live longer, nor will simply attending church or synagogue. "Going to church doesn't do anything. Religion only makes a difference in your life if it really makes a difference."

He distinguishes between intrinsic and extrinsic believers and says evidence indicates intrinsics experience the strongest health benefits. Extrinsics, he says, use religion to obtain non-spiritual goals, such as finding friends and achieving social status or power. Like Dana Carvey's Church Lady character on Saturday Night Live, they often slip into legalism and pass judgment on themselves and others. Intrinsics, on the other hand, see faith as the principal motivating force in their lives, either consciously or unconsciously, affecting everyday behavior and decisions.

Does it make a difference what religion the intrinsic believer practices? "The differences between a devout Jew or Christian or Muslim are very, very slight," says Koenig. "The key is to be committed to God and to community."

Despite the mounting evidence for good health, Koenig says he understands that many Americans are turned off, even wounded, by formal religious experience, and for good reason. Some have experienced negative relationships with ministers, priests, or rabbis. Others see church social circles as cliques that practice exclusion. Religious groups can seem intolerant or insensitive to those who are "different." Every day, believers fall short of spiritual ideals and hypocrisy rears its double-talking head. But Koenig says those shortcomings don't diminish the essence of what faith really means. "It's hard for the secular and the religious to coexist in the same mind. Religious faith appears to go completely counter to evolution. There is no competition to survive. You're actually seeking to love your enemy. Maybe we want that promotion to regional manager, but do we also want to love the other person who's vying for the same position? It's hard to do."

Koenig says the key to faith's influence on health may involve the ultimate paradox, found in many prominent religions, that the "worldly self must be extinguished," that one must "lose one's life in order to find it." "It's actually a very clever way to be selfish," he says. "We still don't know how that kind of 'suffering' on our part helps us, but it seems it could be true."

So should we become more religious in order to live longer, healthier lives? Dean of the Chapel William Willimon says emphatically, "No. It doesn't work that way." He sees Koenig's research findings more as a "gracious byproduct" of faith and worship for its own sake.

"It seems to me that we worship God because God is God and we are not, or because God loves us and we love God," says Willimon. "We don't worship God in order to get more money or a lower heart rate. The main event is God. If that leads to better physical health, fine, but that's not the goal. Unfortunately, we Americans are such utilitarians, judging all people and experience on the basis of 'what will this do for me?' "

Stanley Hauerwas, Gilbert T. Rowe Professor of Theological Ethics, agrees with Willimon. "Such a functional view of religion poisons and negates the whole purpose of religion until it no longer matters whether what you believe in is true or false."

For his part, Koenig argues that it's not his goal for atheists and agnostics to adopt faith to achieve better physical and mental health, nor would it work. "That would be an 'extrinsic' use of religion--religion as a means to another end, rather than as an end in itself. Such a manipulation of faith has actually been correlated with worse health and greater unhappiness."

Beyond the question of faith leading to longer, healthier lives are issues of the impact of religion during the final days. The Institute on Care at the End of Life will strive to improve research, education, and practice for those near death, an effort made possible through a $13.5-million gift arranged by hospice pioneer Hugh Westbrook M.Div.'70. An ordained United Methodist minister, Westbrook specialized in ethics and pastoral care while a student at Duke. His interests led him to focus on hospice care as a chaplain in training at Duke Medical Center, where he was assigned to terminally ill cancer patients. "What I learned through that experience certainly stuck with me to this day," he says.

After leaving Duke, Westbrook developed and taught a course on death and dying at a community college in Florida. That course paved the way for the opening of his first hospice in southern Florida in 1976. In 1978 he co-founded the VITAS Healthcare Corporation, which now provides hospice care to more than 32,000 patients and bereavement services to more than 90,000 people annually across the country.

"If you are terminally ill, dealing with a life-threatening illness, the health-care system is oriented toward a cure--and it should be," he says. "But there are times when medical science can't do anything to prolong life, when it comes time to address quality-of-life issues like controlling pain and living out final days with as much dignity and comfort as possible."

The Duke institute will be the first of its kind in the nation, "which is unusual, since people have been dying for a pretty long time," says Westbrook. "That says a lot about the status of end-of-life care. It is something that happens every day, and we avoid talking about it every day." He says he hopes Duke's effort will inspire the creation of similar programs in other locations, especially as society deals with an aging baby-boom population and the increasing need for hospice care.

Psychiatrist and professor Keith Meador is director of the institute. "We want to reshape the understanding of care for people who are dying," says Meador. "From a religious perspective, it's nothing new--tending to the sick and dying is as old as the Judeo-Christian tradition itself--but culturally I think we've been afraid to see end-of-life care as being integral to living well. Part of the problem is our denial of death."

Meador, who holds degrees in theology, public health, and medicine, says he believes most physicians are taught to think of death as a failure of medical care. "How many of us want to deal with something perceived as failure? Obviously many practitioners will distance themselves from a dying person." Meador expects the institute to help medical caregivers develop new models for thinking about dying and frameworks that combine theology and medicine, and to help doctors address spiritual issues with more candor and respect.

"Dying demands that people examine religious and existential dimensions of their life," says Divinity School dean L. Gregory Jones M.Div. '85, Ph.D. '88, whose calling to ministry was solidified after his father, former Divinity dean Jameson Jones, died of a heart attack. "The institute is a way for the Divinity School to reclaim important connections between health care and the church. We want to help doctors and clergy provide a third alternative to the dying, one beyond aggressive intervention or physician-assisted suicide."

James Tulsky, who directs the Program on the Medical Encounter and Palliative Care at the Durham VA Medical Center, concurs with Meador and Jones that spiritual issues are not emphasized nearly enough in end-of-life health-care settings. "Our research with patients about the attributes of a good death has taught us that spiritual completion ranks second only to pain control on their list of priorities." Medical researchers in the institute will also focus on developing new pain medications and pain therapies.

In the public-policy realm, the institute will pair up with one or more historically black colleges to address issues of hospice care in African-American communities, traditionally neglected by the hospice industry. Researchers and caregivers will also establish a cooperative network with the UNC-Chapel Hill School of Social Work, the department of palliative care and policy at King's College-University of London, and St. Christopher's Hospice of London, where the modern-day hospice movement began. The institute celebrated its official coming-out this March by bringing international experts to Duke for the symposium "Opening Doors: Access to Care at the End of Life."

Even as the new institute is being launched, the Divinity School and the School of Nursing have joined together to create a new parish nursing track called the Health and Nursing Ministries program. Funded by a grant from The Duke Endowment, the program will accept its first class this fall. Nursing school dean Mary Champagne says it will enable nursing students to combine master's-level work in theology with advanced nursing practices. "Nurses always have the desire to reach people," says Champagne. "I believe we've created an innovative way to bring care to the community. And nurses will expect to learn a great deal from congregations as well."

The tradition of parish nursing has been around in some form since at least the second century in Europe, when the Catholic Church saw organized public care of the sick as an integral part of bearing witness to the Christian gospel. In the Middle Ages, several monastic traditions took up care of the sick as a direct way to do "God's work," while at the beginning of the twentieth century in the United States, many public-health nursing societies held church affiliations.

Besides the Institute on Care at the End of Life, Meador directs the Health and Nursing Ministries. He says the program is a perfect fit for nursing education because nursing has historically been the one health-care discipline that focused consistently on being with the chronically ill and suffering. "By its very nature," says Meador, "nursing possesses the moral resources to resist the technical, consumerist, and impersonal pitfalls that are excesses of contemporary medicine." Associate director Ruth Ouimette, a clinical professor at the nursing school, recognizes the idea's potential. "The opportunity to teach nursing students and divinity students together is going to make a big difference."

A big difference indeed. Programs like the Institute on Care at the End of Life and the Health and Nursing Ministries are important first steps in mending the once-antagonistic relationship between health care and religion. As their ideas become more accepted, physicians, nurses, and patients may feel more comfortable discussing issues of faith as they relate to dealing with chronic and terminal illness --and, perhaps, as they relate to dealing with life-long questions of health and health care.

Toward this end, regardless of study results or the establishment's acceptance of his theories, Harold Koenig offers this advice to the non-religious: "Keep an open mind to the existence of God in your own life and in society. Perhaps discuss God and faith with a religious person you respect, someone who will listen and accept you without being judgmental. And bear in mind that cutting-edge scientific disciplines such as molecular biology and astrophysics point increasingly toward order rather than sterile chaos in the universe."

Kicklighter '86 is a freelance writer in Carrboro, North Carolina.

The photographs of Duke Chapel's stained-glass windows are from the collection taken by Ian Sutherland as a 1985 archival project sponsored by Friends of the Chapel. (See "Gazette," May-June 1996 issue, or www.dukemagazine.duke.edu/alumni/dm4/dm4.html.)


Photo: Ian Southerland

Future historians will judge the moral worth of the baby-boom generation by the way it cares for the sick, frail, and elderly, said Ira R. Byock, M.D., a panelist at the inaugural symposium of Duke's new Institute on Care at the End of Life. "Opening Doors: Access to Care at the End of Life" attracted more than 300 participants from around the country in March.

Unless this challenge is addressed, Byock foresees "a negative change in social and cultural history that will be as profound as the Dark Ages. We could potentially be looking at human warehouses that would make the nursing homes of today look like luxury hotels."

Medical ethicist William F. May said the rise in medical costs--which, since World War II, have risen from 4.5 percent to 14 percent of the GNP--and the current shift to managed care means that doctors spend less time with patients, as little as eight minutes in some settings. May called the result the "Disneyfication" of medicine. "Walt Disney's solution to the chronic costs of his theme parks--expensive real estate, equipment, personnel--was to process people fast. The same thing is happening in our health-care system." Instead, May said, caregivers should strive to "honor each person's dying and accompany it."

May listed three classical virtues requisite for that task: prudence, fidelity, and public spiritedness. Prudence, which he described as discernment or attentiveness, requires that both the patient and caregivers "take in what's out there to offer a fitting and appropriate response." Fidelity entails caregiving that is disinterested, a concept at odds with the marketplace. The caregivers' interests "should be trumped by the interests of the patient," as he put it. "Doctors have tended to think of themselves as Lone Rangers appearing out of nowhere and disappearing into nowhere in offering their solitary services to help the patient." Public spiritedness calls for "health-care practitioners who act in concert with others for the public good."

The medical establishment itself is a major barrier to improving end-of-life care, said Kathleen M. Foley. An attending neurologist in the Pain and Palliative Care Service at Memorial Sloan-Kettering Cancer Center in New York, Foley is also director of the Project on Death in America. "Physicians and all health-care professionals lack knowledge in the care of the dying," she told the "Opening Doors" audience. "We have very good data to suggest that they inadequately assess and treat pain, inadequately assess and treat psychological distress, and have little understanding of the spiritual needs of patients."

"Unless we can offer some sort of care and support for the family, as patients become sicker and sicker, people and society are looking at ending life abruptly," said Nessa Coyle, a nurse who directs the Supportive Care Program, Pain and Palliative Care Services, at Memorial Sloan-Kettering. The care of very sick individuals is primarily provided by one or two people, usually women, she said. "What could be a time of growth and fulfillment and putting a life into perspective [instead] can become a very destructive period. Family members are exhausted because of lack of support, lack of understanding of how to care for symptoms, lack of attention to details to the process of dying."

Panelist Arthur Frank, a medical sociologist and cancer survivor, said that managed care's shift of "more and more responsibility for the ill person onto the family, and utterly euphemistically onto the community," comes at an incredible cost. "Now that society is organized into two-income families and nuclear-family housing, to offload the care of the sick and elderly onto families is simply cruel."

Research data reveal that a significant group of people lack access to hospice and palliative care, including minority groups, the elderly, those with less education, and those who are cognitively impaired. Panelist Judi Lund Person, president and chief executive officer of Hospice for the Carolinas, said that only 20 percent of the U.S. population gets hospice care. Since death "happens to 100 percent of us," she said, "one of our challenges is to allow more people access."

In the discussion, Duke's Karla Holloway, dean of the humanities and social sciences and professor of English and African-American literature, said the structure of the interdisciplinary institute illustrates a comprehensive approach to "complex public-policy and cultural issues, as well as the medical and ethical issues."

The Institute on Care at the End of Life, based at the Divinity School, includes representatives of Duke's schools of medicine, nursing, and divinity, as well as the School of Social Work at the University of North Carolina at Chapel Hill and North Carolina Central University in Durham.

--Elisabeth Stagg

Stagg is associate director of communications for Duke's Divinity School.

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