Religion, spirituality, health and medicine: Why should Indian physicians care?S Chattopadhyay
Erasmus Mundus Master of Bioethics Fellow, Department of Ethics, Philosophy and History of Medicine, University Medical Centre St Radboud, PO Box 9101, 6500 HB Nijmegen, The Netherlands
Religion, spirituality, health and medicine have common roots in the conceptual framework of relationship amongst human beings, nature and God. Of late, there has been a surge in interest in understanding the interplay of religion, spirituality, health and medicine, both in popular and scientific literature. A number of published empirical studies suggest that religious involvement is associated with better outcomes in physical and mental health. Despite some methodological limitations, these studies do point towards a positive association between religious involvement and better health. When faced with disease, disability and death, many patients would like physicians to address their emotional and spiritual needs, as well. The renewed interest in the interaction of religion and spirituality with health and medicine has significant implications in the Indian context. Although religion is translated as dharma in major Indian languages, dharma and religion are etymologically different and dharma is closer to spirituality than religion as an organized institution. Religion and spirituality play important roles in the lives of millions of Indians and therefore, Indian physicians need to respectfully acknowledge religious issues and address the spiritual needs of their patients. Incorporating religion and spirituality into health and medicine may also go a long way in making the practice of medicine more holistic, ethical and compassionate. It may also offer new opportunities to learn more about Ayurveda and other traditional systems of medicine and have more enriched understanding and collaborative interaction between different systems of medicine. Indian physicians may also find religion and spirituality significant and fulfilling in their own lives.
Keywords: Religion, spirituality, dharma, Hinduism, health, medicine, medical ethics, western medicine, Ayurveda, complementary and alternative medicine
There was a period in not-so-distant past when practitioners of modern medicine considered patients' religious beliefs and practices at best irrelevant and at worst a problematic superstition.  Thus, religion and spirituality were mostly ignored in medical practice. Now, the scenario has changed remarkably. Several books on religion, spirituality, prayer, healing and health have been authored by physicians and found their rightful place among popular literature. ,,, Several research articles, commentaries and reviews on the interplay of religion, spirituality, health and medicine have been published in major medical, behavioral medicine and public health journals ,,,,,,,,, and the number of scholarly articles on the subject has increased about six-fold, from 300 in 1975-79 to about 1800 in 1995-2001. 
These changes have not only been confined to individual practitioners, but also have permeated institutional and professional bodies. Organizations including the American Psychiatric Association, American Psychological Association, Accreditation Council for Graduate Medical Association, American Academy of Family Physicians, American College of Physicians and Association of American Medical Colleges have stressed the need for addressing religious and spiritual issues, in patient care as well as in training of healthcare professionals.  More than 80 US medical schools now offer courses on spirituality as part of their curriculum.  Medical students in the West are now learning more about non-Western religions and the medical ethics of several faith traditions and are acquiring the skills of taking spiritual history of their patients. ,
Since the beginning of the recorded history of human civilization, religion and medicine have been intertwined, having a common origin in the conceptual framework of the relationship amongst human beings, nature and God. In Egyptian medicine, the priests acted as physicians and delivered natural curative measures using mainly plant products.  Ayurveda , the Hindu system of medicine, had its roots in ancient religious texts of the Atharbaveda. To Hindu sages and monks, knowledge in medicine was sacred; God being the ultimate source of this knowledge of life. , The Buddha (563-477 BC) instructed his disciples to nurse the sick. Asoka, the Buddhist emperor of India, made provisions everywhere in his kingdom for medical treatment for both men and animals.  In the early years of Christianity, religious groups established hospitals in the Western world to provide medical care to the sick.  Islam also played a great role in development of modern medicine by pursuit of knowledge, developing techniques and establishing centers for medical education.  This close relationship between religion and medicine continued for centuries and was interrupted when scientific methods started to be increasingly used for understanding nature and disease towards the end of the 17 th century. ,
Historical events such as persecution of Galileo (1564-1642) for supporting the Copernican view of the universe widened the gap between organized religion and science. Since the time of Newton (1642-1727), scientists accepted the view of material reality as governed by physical laws and attempted to keep faith and religious perspective separate from science and biomedicine. Spectacular advances in the application of scientific methods and technology in the 20 th century led to widening the chasm between modern medicine and religion/spirituality. 
However, as chronic physical diseases, characterized by slow dying process, gradually occupied the specter of disease and death in the late 20 th century, the notion of healing of the whole person with care for the body, mind and spirit started gaining greater prominence. Further, advancement in technology made healthcare increasingly mechanized. For example, sustenance of life for an indefinite period became possible, thus blurring the distinction between life and death. Healthcare professionals were confronted with existential questions of life (e.g. meaning of suffering and death) that have been addressed, traditionally and historically, by religion and spirituality. It is no surprise, then that the biopsychosocial-spiritual model of care  made its entry into the world of modern Western medicine with the aim of restoring the missing art of healing.
Religion and spirituality may mean different things to different people. Contemporary scholars have reached a fair degree of consensus to characterize religion, spirituality and religiosity. The word 'religion' comes from the Latin 'religare' ("to bind together").  Religion is "a set of beliefs, practices and language that characterizes a community that is searching for transcendent meaning in a particular way, generally based upon belief in a deity." , Religion thus organizes the collective experiences of a group of people into a system of beliefs and practices. Religious involvement or religiosity therefore refers to the degree of participation in or adherence to, the beliefs and practices of an organized religion.  Researchers have also differentiated between intrinsic and extrinsic religiosity. Intrinsic religiosity refers to "living" a religion - practicing and believing for its own sake. Extrinsic religiosity refers to "using" a religion, that is, practicing and espousing beliefs for the sake of something else other than religious pursuit. ,
The word 'spirituality' comes from the Latin ' spiritualitas' ("breath.").  It refers to a person's or a group's relationship with the transcendent.  It has also been characterized as an experiential process whose features include quest for meaning and purpose, transcendence (i.e. the sense that being human is more than simple material existence), connectedness (e.g. with others, nature or the divine) and values (e.g. love, compassion and justice). , It appears that compared to religion, spirituality is a broader concept. , Most institutionalized religions aim to foster spirituality. It is also important to remember that religiosity and spirituality are not mutually exclusive concepts and therefore they can overlap and also exist separately.  An appropriate model for addressing patients' religious concerns and/or spiritual needs into the healing process has been felt necessary. ,
"Nothing in life is more wonderful than faith- the one great moving force which we can neither weigh in the balance nor test in the crucible... Faith has always been an essential factor in the practice of medicine... Not a psychologist but an ordinary clinical physician concerned in making strong the weak in mind and body, the whole subject is of interest to me,"  wrote Sir William Osler, in the British Medical Journal, about a century ago. The importance of faith was thus not unknown to the physicians. Two related developments in the recent past have changed the ethos of modern Western medicine: a growing body of scientific research on the relationship between religion and health and patient perspective on spiritual issues.
Scientific research on religion, spirituality and health: A large number of published empirical studies have shown consistent positive association between religious involvement and better outcomes on individual and population health. ,,, Although some of these studies have certain methodological and analytical limitations, ,, a growing body of scientific studies shows that religious involvement has salutary effects on physical and mental health.  People have better mental health and greater adaptability to stress if they are religious.  Not only are religious beliefs and practices associated with significantly lower anxiety, lesser degree and frequency of depression, lower suicide rates, less substance abuse but they are also associated with greater wellbeing, hope and optimism, more purpose and meaning in life, greater marital satisfaction and higher social support. 
Religious involvement is also shown to have had beneficial effects on physical health.  Several clinical and epidemiological studies suggest that religious people are healthier, live with healthier lifestyles and require lesser access to health services. , Religious involvement and practices have been found to be associated with reduced death rates from cancer, lower rates of heart disease, emphysema and cirrhosis; lower blood pressure and lower levels of cholesterol, reduced rates of myocardial infarction and increased longevity. ,,,,, Although the evidence suggests a causal association, it is not conclusive in nature. 
Spiritual needs of patients: For many people, religion and spirituality are a significant part of who they are. Many patients turn (more) to religion and faith as they try to find meaning in their illness and cope with their altered life-situation. Religious faith and spiritual coping has been observed in patients with ailments such as asthma, chronic pain, coronary artery disease, cancer, human immunodeficiency virus (HIV) disease, renal disease, burns and fracture.  Illness, disability and death profoundly affect life and impose a demand to re-assess the values and attitudes towards life, raising some existential questions. When a patient consults a physician to determine the cause and treatment of an illness, he/she may also ask questions (e.g. "Doctor, why did this disease happen to me? Why me?") that are beyond the domain of modern scientific medicine. , Medicine simply cannot ignore the broader perspective of a patient as a whole person and hence physicians need to be attentive to patients' emotional and spiritual needs.  If these needs are not addressed, internal struggles may result in existential crisis leading to dejection and perception of being abandoned (e.g. 'God does not care for me'). The unmet spiritual struggles take a toll on recovery and survival with increased risk of death, poor mental health and low quality of life. The link between depression and desire for hastened death, suicidal thoughts and hopelessness has been consistently found in the studies of medically- and terminally-ill patients and spiritual wellbeing is inversely related to depression. Further, emotional and spiritual needs of the patients have been found to play a significant role in finding hope, strength, coping mechanism and patient satisfaction.  Thus, addressing emotional and spiritual needs is very important in providing compassionate holistic care.
Do patients want physicians to address their spiritual concerns?
Several studies show that the majority of patients want their physicians to acknowledge religious issues and address their spiritual needs. ,,,, They appreciate it if the physician inquires about the patient's religious beliefs, , and believe that physicians should consider patients' spiritual needs. Many patients even want their physicians to pray with them. But very often the patients did not find any physician who had ever discussed their religious beliefs or spiritual needs. ,, It is noteworthy that patients' interest in physicians' spirituality and their agreement with physician prayer increased with seriousness of ailments- 19% during an office-visit, 29% in hospitalization and 50% in near-death scenario.  The most acceptable situations for spiritual discussion were life-threatening illnesses (77%), serious medical conditions (74%) and loss of loved ones (70%). Among those who wanted discussion of spirituality, desire for physician-patient understanding (87%) was the most important reason for discussion. Many patients believed that information concerning their spiritual beliefs would influence physicians' ability to encourage realistic hope, give medical advice and also change medical treatment. 
How often do physicians address the emotional and spiritual needs of their patients?
Many physicians also think that the emotional and spiritual issues are important in clinical care. In a study  of physician preferences regarding spiritual behavior, about 85% of physicians believed they should be aware of the patients' spirituality. However, most would not ask about spiritual issues unless a patient was about to die. Family practitioners were more likely to take a spiritual history than general internists.  Another study found that less than 10% of physicians routinely initiated spiritual history.  There are a number of reasons for this apparent discrepancy between what physicians think they should do and they really do.  These include lack of training for taking spiritual history, constraint of time, personal reservations and apprehension that addressing religious issues while practicing medicine runs the risk of taking over the role of the priest and clergy in the society. ,
The renewed interest in the Western medical community in breaking down the walls between religion and medicine has important implications for the ethos of medicine in India. The World Health Organization (WHO) has accepted spirituality as an important aspect of quality of life. Understanding the implications and consequences of incorporating religion and spirituality into health and medicine in the Indian context needs a thoughtful, critical and open-minded inquiry.
First and foremost, we will have to consider how religion and spirituality have been historically conceptualized, understood and traditionally practiced and lived in the Indian subcontinent. Religion is translated as 'dharma' in many Indian languages including Sanskrit and Hindi. However, religion and dharma are not precisely the same and they are also different at least etymologically. Dharma comes from the Sanskrit root ' dhri ', meaning 'to uphold, support or sustain,' thus in the original meaning of the word, dharma is what upholds existence- life, and growth- being and becoming. "Dharma is so-called because it supports (beings)."  Explicit declared belief in the existence of God is not an absolute obligatory requirement for all concerned in the Hindu philosophical systems and for following the path of dharma.  Individual and collective social life are embodied in dharma guided by the satguru in the principle of 'live and let live.' As every human being is unique with a unique temperament and personality ( guna and prakriti ), the ways life and growth flourish would have some essential commonality among all human beings as well as unique individuality. Moreover, some contemporary scholars have contended the idea of Hinduism as a monolithic religion.  Everyone who is in the quest for ultimate or transcendent meaning in life could be said to have spirituality. , Thus, dharma, as the way of Ideal-centric life, appears to be closer to spirituality than religion as an organized institution.
Second, any in-depth study of religion, spirituality, health and medicine in the Indian context cannot be complete without revisiting the history of medicine in India. It is also imperative to learn more about the historical relationship between religion and health as has been enunciated in Ayurveda, the traditional Indian system of medicine. Along with prayer, meditation and yoga, Ayurveda is now included in the broad category of complementary and alternative medicine (CAM) in the technologically developed countries like the United States.  Interestingly, there has been an appreciable change in attitude, from outright rejection to humble appreciation, toward these traditional indigenous or complementary and alternative systems of medicine. Many US medical schools now offer courses on CAM as part of their training of medical graduates.  Complementary and alternative medicine is also integrated with modern Western medicine in medical education and practice in Cuba.  Sri Lanka has sustained traditional medicine like Ayurveda in its comprehensive National Health Policy.  Moreover, scientific research on different modalities of traditional, complementary and alternative systems of medicine has further expanded the horizon of existing knowledge about the human body, health and disease. ,, Incorporating religion and spirituality into health and medicine may also open up new horizons in the practice of medicine and promote greater collaboration and enriched interaction between modern Western medicine and indigenous traditional medicine in the Indian scenario.
Third is the 'inhumanity of medicine'  as exists in India. The curriculum followed in Indian medical colleges has hardly undergone any significant structural change since colonial times and still does not offer any study or exposure to philosophy or medical humanities or spirituality or religion. Furthermore, in the absence of any center or department of ethics, philosophy and history of medicine, teaching-learning in these areas of knowledge are, in general, neglected. Academic dishonesty in Indian medical colleges has been reported by conscientious medical teachers.  Monetary interests have influenced practice of medicine and in recent decades, the doctor-patient relationship of altruism and trust has deteriorated remarkably in some quarters. , In this time of erosion of values and virtues, the meaning and purpose of value-free scientific medical education really needs to be questioned. It is desired that tomorrow's physicians would be trained to take care of patients holistically and address their needs in the physical, mental and spiritual realms of life. Incorporating religion and spirituality into health and medicine - both in education and practice - could help make medicine more holistic, value-based and compassionate in nature. Without waiting for a major structural change in the curriculum, clinicians can start teaching the medical students about being respectful toward patients' religious beliefs, the art of taking spiritual history, integrating yoga, prayer and other practices with clinical care and thus make positive quality changes in the ethos of medicine in India.
Fourth is the place of religion and spirituality in the life and health of many Indian patients. Few would contend the idea that religion and spirituality do play important roles in the lives of millions of Indians of different faith traditions and cultures. Both religion and medicine share the common values of care, compassion and service. Religious beliefs and spiritual practices may provide the physicians with new avenues for achieving better health outcomes e.g. advising a patient of Vaishnava (devotee of Vishnu, follower of Krishna or path of devotion) or Islamic background to stay away from smoking or alcohol addiction. Addressing the religious concerns and spiritual needs of patients whose religious and cultural backgrounds differ from those of the physicians would certainly improve physician-patient relationship.
Last but not the least is the important role that religion and spirituality can play in the lives of healthcare professionals of the present and future. As the medical students progress through their medical training program, many of them show declining idealism, cynicism and growing apathy toward the medical profession.  Practicing medicine also takes a toll on life. Physicians at some point of their professional lives may have feel burnt out and depressed, experience lack of motivation, harbor suicidal thoughts, face mental and physical illness and turn to alcohol and drug abuse.  Physicians have been using religion and spirituality as a wellness-promotion practice for their own wellbeing.  Daily spiritual practices might help mitigate physical, cognitive and emotional forms of burnout in medical and mental health practitioners.  Thus, healthcare professionals may also find religion and spirituality not only important in the lives of their patients, but also significant for their own renewal and healing process. 
The strength of modern Western medicine has also been its weakness, in the sense that it achieved remarkable success in diagnosis and treatment of diseases, but neglected the existential questions and spiritual issues that accompany serious illness. Religion and spirituality, intertwined with medicine since millennia, became segregated for a few centuries and they are again coming close to embrace each other. We are thus living in an interesting phase of history. There is paucity of literature and lacuna in understanding about the interplay of religion and spirituality with health and medicine in the Indian scenario. Future research is necessary to comprehend the nature of religious and spiritual faiths and practices of Indian people that may affect their physical and psychosocial health. Furthermore, the importance of knowing how Indian patients would like to see their emotional and spiritual needs addressed by their physicians can hardly be overemphasized. Appreciating the interactive dynamic relationship amongst religion, spirituality, health and medicine provides us with an excellent opportunity to reflect on the past, strive for greater enriched understanding and better clinical practice at the present and have a vision for the science and art of healing tomorrow.
This paper is dedicated to Sri Sri Thakur Anukulchandra (1888-1969). It is the result of research performed as part of the educational programme Erasmus Mundus Master of Bioethics. I am grateful to Rev. Sri Ashok Chakraborty and Rev. Dr. Alok Chakraborty (Deoghar, India) for invaluable inspiration. I would like to thank Professor Dr. Renzo Pegoraro (Padova, Italy) for helpful suggestions, and Professor Dr. Wim Dekkers, Professor Evert van Leewen (Nijmegen, The Netherlands) and Dr. Pascal Borry (Leuven, Belgium) for critical comments. Special thanks are to Ms. Rosemary Bailey (The Oxford University Press, Oxford, UK) for valuable help and Professor Dr. Sujit Chaudhuri (Kolkata, India) for encouraging support.