By Melissa Weber

No matter the variation in definition or application, research shows more and more cancer patients are looking to “spirituality” as a way of dealing with their diagnosis. And physicians are paying attention.

The National Institutes of Health has held conferences on the relationship between health and spirituality. More than 1,200 research studies have been completed to date with more than 70 medical schools now offering course material on spirituality. And, while it has warranted publication of more than 19,000 books, the definition of spirituality often remains in the realm of whoever is discussing it at the moment.

Defining Spirituality
“Spirituality is intrinsic to everyone,” explains Larry Dossey, MD, researcher and author of nine books on spirituality and health. “Everyone searches for meaning in their life whether they’re sick or well, so it’s only natural that this be especially crucial for cancer patients.”

Christina Puchalski, MD, associate professor of Medicine and Health Care Sciences, George Washington University Medical Center (GWUMC), Washington, D.C., and founder and director of the George Washington Institute for Spirituality and Health (www.gwish.org), agrees that spirituality gives a person meaning in life and can be expressed in either religious or broader terms as well. “Spirituality may include other aspects,” she says. “There are spiritual aspects of nature and relationships. Religion offers a set of beliefs that have been written about for years, but not everyone subscribes to that.”

Breast cancer survivor Katalin Eve Roth, JD, MD, preferred that spirituality—not religion—be part of dealing with her cancer. The academic physician at GWUMC says that although she was raised in an orthodox Jewish household, she now describes herself as an agnostic.

“I wasn’t angry with God; I just didn’t get anything from [organized religion]. But what was helpful for me was nature. Spirituality for me is about a connection. I was diagnosed in September of 1998 when we had a beautiful autumn year, and I spent a lot of time taking long walks with friends and with my husband in a park in Washington along the Potomac River.

“Even little things like keeping the bird feeder full so that I could watch the birds made me feel connected, and that feeling is what spirituality is for me,” she says.

Dr. Puchalski says spirituality isn’t always about the external healing of a person—it’s about having the capacity to heal oneself internally.

This self-healing aspect of spirituality in the 21st century contradicts the traditional definition of surrendering to a higher, external power. The old definition draws from rules, religious practices, and a predefined path, whereas the new definition leaves these doctrines behind and feeds off meditative, environmental, and psychological roots. Its diversity predicts only its unpredictability. Thus, how physicians address spirituality with patients, if at all, presents a complex set of questions not easily answered.

Travis Maxwell, oncology chaplain at Baylor-Charles A. Sammons Cancer Center, Dallas, says it’s important that doctors be sensitive to issues of spirituality with patients, adding that medical school is an excellent place to begin discussion.

Dr. Puchalski agrees. She teaches her students and other physicians how to take a patient’s spiritual history with a system she calls the FICA method—questions involving faith, importance, community, and action. “These questions help physicians recognize the needs of their patients because spirituality is an integral part of treating the whole person. Doctors are able to come away from it with the knowledge of how or if to address spirituality and if there’s any action they can recommend to the patient.”

Controversies
Some physicians question taking this leap into a patient’s spiritual life. A recent article in The New England Journal of Medicine suggests religious advice can have a coercive effect and raises ethical questions about a patient’s autonomy regarding religion. The article’s authors say, “Marital status is associated with health, but physicians do not dispense advice regarding marriage. There is evidence that early rather than late childbearing may reduce the risk of various cancers, but we would recoil at a physician’s recommendation that a young woman, either married or single, have a child to reduce her risk of cancer.”

Studies are contradictory at best with one finding that 77% of hospitalized patients wanted their physician to discuss their spiritual needs, and another study concluding an estimated one-third of patients did not want their doctor to ask them about their spiritual life.

“If there’s evidence that something helps patients and they want it, it’s unethical to deny it to them,” explains Dr. Dossey. “Doctors who claim it’s unethical to bring up spirituality with patients are usually uninformed.” He adds that if doctors aren’t willing to talk about spirituality, patients should look to chaplains, family, or friends. “You don’t always have to look to someone in a white coat to help you.”

Despite any debate, studies have proven spirituality’s legitimacy as a complementary therapy. A study on the use of complementary and alternative medicine published in the Journal of Clinical Oncology found that spiritual practices, such as prayer, were used more (80.5%) than any other complementary approach, including vitamins and herbs (62.6%) and movement and physical therapies (59.2%). Other studies have found similar results.

Researchers have also found that people who have regular spiritual practices, such as church attendance, tend to live longer. A study of 1,700 older adults found that those who attended church were less likely to have elevated levels of interleukin-6, which is associated with an increased incidence of disease.

But what it comes down to, says Dr. Puchalski, has nothing to do with living longer or being cured. “Many patients and doctors first think about cure, but spiritual healing is in a different realm than a cure. It’s about doing things that are valuable to you. People suffer, and if they can’t find meaning in that suffering, they can feel destroyed. Spirituality can give them a way to understand their illness.”

Diversity
For those doctors who do tackle issues of spirituality with patients, cultural and religious diversity has led to further concerns that physicians cannot have spiritual discussion without possibly offending the patient. The growing religious diversity in the United States has brought not only immigrants, but their faiths as well—Buddhists, Muslims, Hindus, Jews, Sikhs, and Jains, to name a few.

But Maxwell says that’s where chaplains can step in. “The chaplain’s role is to bring spiritual resources to the bedside, and we have resource people from almost all religious backgrounds who are available to come to the hospital.”

The Effect of Prayer
Debra Neal, a non-Hodgkin’s lymphoma patient, says she feels a very strong spiritual presence in her life. “I’ve received so many prayers,” says the 47-year-old from Fort Worth, Texas. “I feel like God puts you on Earth when He wants to and He takes you when He wants to. We have loved ones on both sides that are separated physically, but mentally and spiritually, they’re not separated at all.”

Similarly, Dr. Dossey says prayer isn’t necessarily about being cured. “The point is not to pray your cancer away,” he says. “It’s not about whether you get past the illness, because there’s the abiding certainty that there’s something after you die. It’s about the implication of survival of bodily death.”

Even intercessory prayer (praying for others) to improve health has become a popular method of investigation. An analysis of 23 studies on intercessory prayer, published in the Annals of Internal Medicine, found that 57% of the studies showed a positive effect and “the evidence thus far merits further study.” And yet, Dr. Puchalski says the benefits of intercessory prayer cannot be measured by a patient’s outcome.

“I don’t think it’s possible to have a controlled experiment with prayer,” she explains. “I question the premise, because when you talk about prayer in religious context, prayer is not for your own will, it’s for the will of God—Thy will be done. God’s will may be life and it may be death.”

Maxwell says he’s also suspicious of some prayer research. “To say here’s the group that was prayed for and here’s the group that wasn’t—how do you do that? How do you know they weren’t prayed for? How do you get an honest control group?”

Struggling with Spirituality
Some cancer patients will experience depression and anger after diagnosis, and are thus not open to spirituality. Dr. Dossey says people set up inappropriate expectations when it comes to spiritual healing. “Most people have an innate sense of spirit that will flower if they simply open themselves to it,” he says. “Trying to force it is the wrong thing to do.”

Dr. Dossey suggests patients devote a period of time each day to taking a walk or just turning off the television and retreating into meditation and quietness.

In the end, the goal seems to be an individual resolution for spiritual experimentation that leads to a journey and destination as unique as the person. No amount of data can explain what spirituality is or how it works. But those who experience it can offer some insight.

“I feel like when God puts you on Earth, it’s like going on vacation,” says Neal. “When it’s time to die, it’s like going home. It’s always nice to go home, and there’s nothing to fear. I think since I don’t have a fear of death, it doesn’t worry me. And when you don’t worry about things like that, you can be more concerned with your body and healing.

“But I do want to stay on vacation longer.”