Separating doctoring from doctrine

You may recall how I’ve criticized the infiltration of woo into medical school and medical education in general. Such an infiltration threatens the scientific basis behind the hard-won success of so much of modern medicine over the last century. Unfortunately, woo isn’t the only threat to scientific medicine. Now, there is a growing movement that insists that doctors should ask you about your spiritual life and make religious practices a part of medicine, as Dr. Richard P. Sloan described in an editorial in the L.A. Times that I can’t believe I missed:

HOW WOULD you like your doctor, at your next examination, to ask not only about your diet and symptoms but about your spiritual life?

How would you like your surgeon to ask, while you’re on the gurney ready to be wheeled in for an operation, if you’d mind if he says a quick prayer?

Or if he suggested that perhaps you should?

These questions are not far-fetched these days. A concerted effort is underway to make religious practices part of clinical medicine. About two-thirds of U.S. medical schools now offer some form of training on the role of religion and spirituality in medicine, according to Dr. Harold Koenig of Duke University.

With support from the National Institutes of Health, researchers are now studying the effect of third-party prayer on cancer patients. Research on the connection between religious activity and cardiac health was published in the Lancet, one of the top peer-reviewed medical journals. The John Templeton Foundation, whose annual prize on spiritual discoveries exceeds the amount of the Nobel Prize in medicine, has funded dozens of medical researchers, some at top-tier institutions, who claim an association between religious devotion and better health.

Some prominent physicians are calling for the wall of separation between religion and medicine to be torn down. They declare that the future of medicine is prayer and Prozac, and they recommend that doctors take a “spiritual history” during a patient’s initial visit and annually thereafter. Walter Larimore, an award-winning physician, for instance, has declared that excluding God from a consultation should be grounds for malpractice.

I started to grind my teeth when I read that last line, my face contorted into a hideous grimace, and my hand twitching as it wanted to throw something at the computer screen. Some ScienceBloggers and a few other physician bloggers may be on the verge of becoming apoplectic when they see that line. In fact, I would think that even highly religious people would see what a potentially frightening statement that is.

Religion and God should have little or nothing to do with how a physician operates. Don’t get me wrong. I’m not at all opposed to hospitals’ asking patients what their religion is, if they have one, and providing chaplains to counsel them and pray for them. This brings comfort to the patient and the family and has a legitimate role in any hospital, as long as it doesn’t go overboard, as the Veterans Administration is alleged to have done. I just find the contention that doctors should somehow be obligated to ask a patient about religious practices (except in very specific cases where a patient’s religious practices may impact on his disease or treatment, such as the case of Jehovah’s Witnesses, for example, who refuse all blood products based on their religion) to be unsupported by evidence and that bringing too much religion into the physician’s end of the practice of medicine could lead to all sorts of problems. Even worse, it’s the height of hubris to assert that not asking a patient about religion and God during a consultation is “malpractice.” That is, in essence, making a claim for the value of religion in medical care for which there is little or no evidence, as Dr. Simpson points out:

But before organized medicine decides that religion has any value in physical healing, several things ought to be considered. First, the scientific evidence supposedly linking religious practices with better health is shockingly weak — so bad, in fact, that if we were discussing drugs, the Food and Drug Administration would have to find them unsafe and ineffective. Most research studies that claim to show how religious involvement is associated with better health fail to rule out other factors that might account for the relationship.

We all agree, for instance, that there is a real connection between lung cancer and carrying a cigarette lighter in your pocket, but no one thinks that the lighter causes cancer. The lighter is a marker of another factor — smoking — that has been scientifically proved to cause the cancer.

In precisely the same way, religious practices are likely to be markers of some other factor — for example, social support from family, friends or the community or, perhaps, the absence of behavioral risk factors — that may lower the risk of disease.

Studies that show, for example, the health benefits of attending worship services or reading the Bible often make this mistake. A study of residents of Washington County, Md. — the largest study ever to demonstrate that church attendance was associated with reduced mortality — made precisely this error; it failed to recognize that attendance itself was a marker for good health.

I believe this is the study to which Dr. Sloan is referring. I noted a couple of potentially obvious confounding errors right there that could account for the difference. Those who smoked cigarettes and/or drank more than 45 alcoholic beverages a month were considerably likely to attend church regularly (the odds ratio being 0.4 and 0.45, respectively), and those who attended church were more likely to quit smoking or drinking over the 28 year study period. That alone could potentially explain the most of the results and supports Dr. Sloan’s contention that frequent attendance at church services may be a marker, rather than a cause of the observation of decreased mortality. Another point is that the decrease is not that large, with an mortality odds ratio of less than two for the non-attenders, and in any epidemiological study we’re always a bit wary of odds ratios less than two. One can speculate that it is possible (or even likely) that attendance at religious services promotes smoking and drinking cessation, but that does not mean that religion itself is the reason. Any large group activity that fosters social connections and makes a point of reinforcing healthy behavior would likely have the same effect.

Then, of course, there’s the infamous intercessory prayer study, published earlier this year. This study examined the effect of intercessory prayer on the recovery of patients undergoing coronary artery bypass grafting (CABG), and its findings were that intercessory was not associated with a decrease in complications or mortality. Indeed, patients who received intercessory prayer and knew they were being prayed for tended to do somewhat worse. The authors speculated that a patient who knew he was being prayed for might assume he was in worse condition and that that attitude might affect the outcome, but that was just speculation. (My speculation on this latter result is that it was probably a statistical fluke, but I have to consider the reasonable possibility that it was not.) Indeed, there is another intercessory prayer study that found no difference in length of stay, cardiac arrest, hypertension, or pneumonia attributable to intercessory prayer on patients in the coronary care unit, although there was a just barely statistically significant trend to fewer complications overall.

The bottom line, though, is that studies trying to link religiosity and/or prayer with better health or better outcomes are plagued with methodological difficulties. For one thing, in many of them, the primary relationship being studied has nothing to do with religion at all, and correlations between religion and outcomes are buried in the text or a small table as a side issue. In addition, these studies look at correlation, and correlation does not necessarily equal causation. Some of them even try to correlate lots of variables to religious observance without doing the statistical correction necessary. (When one looks at multiple potential correlates, looking at more variables increases the chance of picking up a spurious “correlation” by random chance alone, and statistical corrections are necessary to account for this tendency.) Also, to demonstrate causation, some sort of interventional trial needs to be done. (The CABG study was an interventional study.) Epidemiological studies alone aren’t enough. Finally, publication bias could well be at play here, because studies that find a positive correlation between religious observance and health are inherently more “interesting” and would be more likely to be published, and published in better journals, than studies that fail to find such a link.

There are even other confounding variables, some of which can be shockingly simple and one of which Dr. Sloan described in an earlier article:

In 1971, George Comstock, a very senior epidemiologist at Johns Hopkins, published a paper showing that attendance at church was associated with reduced mortality at a follow-up seven years later. This study is cited over and over by proponents of this position. What these proponents never report is that seven years later, in 1978, Comstock retracted that finding, on the following basis. He said that he failed to account for the fact that by looking at people who go to church and contrasting them with people who don’t go to church, he missed the effect of previous illness. That is, people who are already too sick, i.e., are functionally incapacitated, can’t go to church, and people who are already too sick die at a higher rate than people who aren’t so sick. So the effect of church attendance on mortality was entirely wiped out by considering functional status. Comstock publicly retracted this finding in a paper published in a major journal in 1978.

Thus, the state of the evidence supporting a link between church attendance or religiosity and better health or better health outcomes is tenuous, but there may indeed be such a link. Such a correlation may even indicate causation. However, there is a paucity of evidence that would allow us to make either conclusion with any confidence at all. Given that, what must take overwhelming precedence in considering whether physicians should be inserting themselves into the religious lives of their patients, except in extreme circumstances are the bioethical implications:

More problematic still is the actual effect on patients when physicians abuse the privileged authority inherent in the role of the doctor by manipulating the religious sentiments of frightened and vulnerable patients. Physicians risk transgressing other ethical boundaries when they tell their patients that religious practices can improve their health. Asserting that prayer can promote recovery can lead patients who fare poorly to question their spiritual devotion and to experience guilt and remorse over their supposed religious failures.

This is not at all unlike the Hoxsey quacks telling patients that the Hoxsey therapy can cure 80% of cancer patients, while saying that the ones who weren’t cured had a “bad attitude“; i.e. didn’t believe in the treatment enough!

Here’s another aspect of this to chew on. If you are a Catholic, would you feel comfortable having a Muslim or a Jewish doctor asking about your religious beliefs? What about the other way around? If you’re an atheist, I’d be willing to bet that you’d find such questioning intrusive and offensive. And think about this: If a doctor believes that religiosity is truly good for your health, it won’t be long before he starts trying to determine which religion is better for health outcomes. What if, as is likely, he concludes it’s his religion , and what if his religion is not your religion? Or what if it is “determined scientifically” that belief in God is more effective in promoting health than belief in Allah, or vice-versa? Should doctors then start urging their patients to convert to the more “healthy” religion? Then there are logical problems advocates of inserting religion into the doctor-patient relationship face:

They say…that they would not force religion onto anybody. They will only recommend religious activity, or engage in religious activity, with their patients, if the patients clearly indicate a willingness to do this. But then they also assert that the evidence is overwhelming that religious activity promotes health. It seems to me that by taking the former stance, that they will only engage in religious activity if their patients are open and receptive to it, they are derelict in their duties as physicians. It’s like saying to a patient: “You’ve got pneumonia. What’s your feeling about antibiotics? Are you in favor of them, or not?” Physicians don’t do that. They say: “I recommend that you take antibiotics,” because there’s a consensus that antibiotics are an appropriate treatment for pneumonia. Nobody disputes that. If they’re saying the evidence is so strong that religion is associated with good health outcomes, then they’re derelict in their duty by not recommending religious activity to every patient, regardless of their feelings!

The second ethical problem…is the limits of medical intervention. There is no end to the number of factors, personal and socioeconomic, that influence health outcomes. For example, it is well-established that marital status confers benefits to health. While this marital effect may be stronger for men than for women, in general people who are married live longer and they are more healthy than people who are not. If you as a single person were to visit a physician, what would you say if the physician said, “You know, Bob, there’s this massive amount of evidence suggesting that marital status is good for your health, so I as your physician recommend that you get married.” …The reason physicians don’t do it in the case of marriage, and in the case of financial and socioeconomic status, which are also associated with good health, is because we believe there are certain aspects of our lives that are private and personal, and even if they have an impact on health, are out-of-bounds from medicine.

Even in this age of the patient who comes into the doctors’ office armed with a folder full of printouts of the latest research culled from the Internet, of patients who are far more proactive in asking questions of their doctors than even 10 or 20 years ago, we as physicians still have enormous prestige and power, whether we still realize it or not. No other profession is granted the privilege of being allowed to prescribe drugs or treat diseases. In the case of surgeons, no other profession is granted the power to cut into living human flesh legally, the better to rearrange their anatomy for therapeutic effect. If doctors started meddling in the religious life of their patients, they could, believe it or not, still be largely influential. Do we really want that?

None of this is to say that doctors don’t have a responsibility to ask patients about factors that impact their health, like, for example, drinking excess alcohol or smoking. Unlike religious observance, these are factors that can be quantified and for which abundant evidence exists to indicate that these activities impact negatively on a patient’s health. Diet is another such factor. However, there are only relatively rare instances where it is appropriate to ask about a patient’s religion. For example, in my field, we know that Ashkenazi Jews have a much higher rate of breast cancer than most other groups, but even in this case, it’s not so much the Jewish religion as the ethnicity that is important. In the previously mentioned example of Jehovah’s Witnesses, we usually do not ask if the patient is a Jehovah’s Witness. Usually, the patient volunteers the information as justification for refusing a blood transfusion.

Religious belief is very important to a large number of people, and many of these people find comfort in it during trying times, particularly during serious illnesses. Even so, barring far more convincing evidence on a general benefit to health or improvement of outcomes of disease or injury that can be attributed to religion, physicians should attend to evidence-based medicine and leave a person’s religious beliefs (or lack thereof) to the realms of the patient, family, community, and/or church. Doctors are not, nor should they try to be, chaplains, ministers, priests, imams, rabbis, or preachers.