Harold G. Koenig

Medicine, Religion and Health

Medicine, Religion and Health. By Harold G. Koenig, M.D. Templeton Foundation Press, 2008. 234 pages. $17.95.

Review by Lawrence A. Whitney, 2011 | Review by Weiyi Du (William), 2009

Review by Lawrence A. Whitney, 2011

In our late modern era when medicine, health and health care are fraught with challenges, to say nothing of the anxieties and tensions that arise when religion and spirituality are thrown into the mix, Koenig provides a stunningly clear, precise, and erudite treatment of all of these topics together. Dr. Koenig is professor of psychiatry and behavioral sciences and associate professor of medicine at Duke University where he is also the director of their Center for Spirituality, Theology and Health. His presentation in this volume is written in such a way that it is accessible to a lay audience but also provides a significant introduction to the field of spirituality, religion, medicine, and health for academics seeking to gain some traction in the field.

It is significant that Koenig approaches these complex topics with the training of a medical doctor. This background leads him to take an evidence-based approach to understanding the value of religion and spirituality for health. In order to develop an evidentiary basis for the role of religion and spirituality in health, he must do some careful work in the first chapter to provide operational definitions for both terms. He defines religion as unique but multidimensional such that it is measurable and quantifiable in an analytic framework. The dimensions he indicates include beliefs, practices, some sort of ultimate reality, scriptures or teachings, and moral codes, among others. Koenig’s definition of spirituality is interesting because he believes, again for the sake of rendering it a valid basis for evidence, that spirituality should be tied to religious tradition and supernaturalism, even as he believes that his close tie between the two should be loosened for the sake of clinical practice.

There are two potential problems with the way Koenig deploys his operational definitions. First, he is clearly aware of the discrepancies among popular definitions of religion and spirituality, but seems less aware of the inability of religion scholars to achieve a commonly accepted and adequate definition of these terms. Thus, at least a portion of his intended audience will likely find his definitions inadequate. There will be particular struggle with the notion of religion as a unique domain, which is necessary for Koenig to employ religion as part of an evidence-based approach at it circumscribes religion as a discrete realm of life. Second, Koenig is very forthright that the definitions he comes to are preferred for the sake of developing an evidentiary basis for relating spirituality and religion to medicine and health. This is fine in and of itself, but he then fails to adequately explain the differences between his preferred definitions and those employed in the studies he examines throughout the remainder of the volume. For example, he cites a study of Presbyterians, but then extrapolates to the efficacy of religion in general (66).

The second chapter, looking at medicine in the 21st century, may be the most helpful in the whole book in terms of diagnosing the precise point of disjuncture between spirituality and religion, on the one hand, and medicine and health, on the other. Koenig is careful to point out that there is no lack of evidence-based studies of the role of religion and spirituality in establishing, maintaining, and recovering good health in conjunction with modern medical practice. The problem instead lies among physicians who are either unwilling to engage religion and spirituality out of prejudice, or are unwilling to challenge the status quo, which is biased against such engagement. The heart of the problem is both personal and systemic, but lies almost entirely on the side of modern medical providers in the doctor-patient relationship.

In chapter three, Koenig explores positive psychological factors and social support to explore the particular effects those functions have on health. He first explores how the positive psychological factors produced by religious or spiritual involvement can be beneficial in a number of domains of health, and then similarly relates the positive effects of social support that results from religious involvement to such domains. In both cases, it is the capacity of positive psychology and social support to reduce stress that result in positive health effects.

The subsequent chapter then identifies spirituality and religion as sources of these two functions. While these explorations are quite interesting and helpful, it is unfortunate that Koenig never got around to exploring the fact that these functions are not necessarily central to the self-understanding of most religious traditions, and they do not often factor highly in the rationales religious traditions provide for their own healing efficacy. In addition to resulting in a failure to adequately address a part of his audience, namely some religious and spiritual practitioners, his failure to acknowledge that these functions are more peripheral than central to religious and spiritual life leaves him open to challenge on his claim to the uniqueness of the domains of religion and spirituality.

The next six chapters explore the impact religious involvement can have on various genres of health concerns, ranging from mental health to particular systems in the body to longevity and disability. In all of these cases, the primary ways that religion and spirituality influence positive health outcomes is by reducing stress through the engendering of a positive psychological outlook and providing social support. These chapters are probably of greatest interest to practitioners who address these particular genres of health and to patients suffering conditions that fall under one or another of these genres. For religion scholars, these chapters can get a bit tedious as they always return to the same two functions, whereas for medical practitioners they provide a roadmap for effective treatment of particular ailments.

In chapter eleven, Koening provides medical practitioners with a rubric for how and when they should address spiritual issues in patient care, and then goes on to explain what fruits they should expect to harvest from this labor. He begins the chapter by providing seven reasons that practitioners should be concerned to address spiritual issues, ranging from the fact that many patients want to see their religious and spiritual lives incorporated so, to the fact that religion and spirituality have real influence on treatments and outcomes. Of particular interest here is the fact that Koenig addresses, albeit very briefly, the fact that some religious beliefs and practices can interfere with treatments, largely by affecting the patient’s willingness to adhere to a treatment protocol.

Koenig provides four means for physicians to address spiritual issues with patients. First, he strongly recommends getting a spiritual history from patients, and provides an outline of what might be included in such an instrument, with reference to further material for generating such a tool. He then recommends referral to chaplains. His praise and recommendation of chaplains is high, but it would have been good to see some recognition here that chaplaincy programs are vastly underfunded and understaffed. Koenig also recommends that, when a patient desires and a doctor is willing, it is good practice for doctors to pray with patients. His recommendation in this regard is probably the most diplomatically written paragraphs of the volume, and rightfully so as this recommendation will likely be the hardest to swallow for many practitioners. Finally, he recommends that health professionals engage with faith communities, largely for the sake of developing referral networks.

This book is an extraordinarily important contribution to the conversations and debates about the relationships among spirituality, religion, medicine, and health. It is accessible, precise, concise, and learned. The book can be used in a variety of settings, including classrooms in medical schools, in congregational study groups, and in continuing education for practicing physicians, among others. It is rare to find a treatment of a topic at once so comprehensive and flexible. Nevertheless, it should be clear to any reader that this volume is only the tip of the iceberg. There are issues, some of which have been lifted up in this review, from virtually every side of the topic in question, which beg to be addressed more thoroughly, and in some cases they are not addressed all. These issues range in scope from methodology, to content, to the recommendations on offer. At the end of the day, however, the book stands as an icon in the field and as probably the most useful introductory text that could be hoped for at this stage of modern understanding of the relationships among these complex domains of life.

Review by Weiyi Du (William), 2009

Harold G. Koenig, M.D., professor of psychiatry and behavioral sciences and associate professor of medicine at Duke University, is famous for his medical research on spirituality and religion. He is a founder and former director of Duke’s Center for the Study of Religion, Spirituality and Health, and a co-director of the current Center for Spirituality, Theology and Health.

In Medicine, Religion, and Health, Koenig provides an extensive review of the relationship between health, on the one hand, and religion and spirituality, on the other. The thesis of this book is “religion and spirituality can indeed affect health in a scientifically detectable way” (4). The introduction of the book is a guideline for approaching the book’s twelve chapters, which will now be summarized in turn.

In Chapter 1, Koenig defines “religion” and “spirituality” to in order to ground his thesis. The definitions are interchangeable and open to individual interpretations, because “spirituality can be profitably used in two different ways, more narrowly in research and more broadly for patient care” (10). In research, “spirituality” refers to a “personal relationship to the transcendent,” and “religion” means “the institutional aspects of spirituality” (16). In practice, however, these two words are interchangeable (5).

In the next chapter, Koenig establishes connections between spirituality and health: “many patients are religious” and “health problems often give rise to spiritual needs” (23). He then justifies the significance of the research on health and spirituality by invoking the rapid increase of population, the cost of medical care, and the severe deficiency of medical training in spirituality.

In Chapter 3, From Mind to Body, Koenig proposes a crucial point, from psychological and social factors that emotions have influences on the natural healing systems in the body (37). While negative emotions like stress, anxiety, depression, burnout, anger, and hostility can adversely affect physiological systems and medical outcomes, social support buffers the effects of emotional disorders (38, 45).

In Chapter 4, Religion and Health, Koenig argues that religion and spirituality can be beneficial to health in a scientifically detectable way. This point is the crux of his thesis. Three reasons are offered to defend his thesis. First, religion is a personal coping strategy, providing comfort and support to patients. Second, religious people are more likely to involve themselves in “prosocial activities, such as acts of altruism and volunteering,” which are major indicators of better health (65). Third, religion is also a behavioral modifier. The more serious participants of religions are, the more tendencies they will avoid behaviors which are commonly related to emotional disorders and poor health, such as crimes, alcohol use, drug use, etc.

In Chapters 5-10, Koenig scrutinizes six specific areas of human health: mental health, the immune and endocrine system, the cardiovascular system, stress and behavior-related diseases, longevity, and physical disabilities. Because religion functions as a personal coping strategy, prosocial agent, and behavioral modifier, religious people have relatively fewer emotional disorders and tend to engage in activities beneficial to mental and physical health. These six chapters share a similar structure, with the differences only in content, i.e. in six different human systems.

In Chapter 11, Clinical Applications, Koenig offers suggestions to medical professionals on how to address patients’ spiritual concerns. Arguing for the importance of spirituality for health, he encourages physicians to document the spiritual histories of patients when patients express spiritual concerns. Other suggestions include referrals to chaplains, praying with patients, and encouraging patients to establish relationships with spiritual communities. Koenig also offers suggestions on when to address spiritual concerns of patients, potential outcomes following this, and advice on what doctors should not do in such circumstances.

Chapter 12 includes a concise summary of the book: “There is mounting evidence from randomized clinical trials and prospective studies that religious beliefs and practices have positive effects on coping and on speeding remission from emotional disorders…[therefore] religious beliefs have the potential to impact not only mental health but physical health as well” (172). The Appendix consists of key research studies on religion and health, books, internet sites, and academic centers (7).

I appreciate this book, Medicine, Religion, and Health as a clear, simple, informative, and cogent review of scientific studies on the relationship between religion and health.

The structure is highly clear. Koenig identifies his thesis and the sequence of the book at the very beginning. Reading the introduction, from which we can grasp the big picture of the book, facilitates our approaching the book as a whole.

Though the book is written by a medical professional, it is easy to read. The writing style is simple. Certainly, as a scientific study, medical terminology appears; however, it really does not affect reading. The simplicity of language and the clarity of structure make the reading easy.

One of the most impressive aspects of this book is its extensive researches. Koenig quotes at least one study on most of the diseases or dysfunctions of the physiological functions of the human body. For example, Chapter 6 refers to more than 20 sources in 14 pages. In that chapter, he divides the discussion under three categories: “humoral immunity,” “cellular immunity,” and “cortisol and growth hormone.” In the category of cellular immunity, there are subcategories such as T-helper Cells, Natural-killer and Cytotoxic Cells, and Interleukin-6. The reader may not know the function of each cell in its context, but we can grasp the purpose and the result of the study without much difficulty. The studies quoted are carried out everywhere in the world, such as Catholic nuns, Shiite Muslims, and Mormons (99, 102, 124). The studies also cover most of the major medical traditions, for example, Chinese Qigong and Indian yoga (94). The extensiveness of the references not only exhibits the author’s knowledge on this topic, it also strengthens Koenig’s argument.

Compared with references to numerous research studies in the book, it is also impressive how cautiously and uncertainly Koenig argues his hypothesis that religion and spirituality can be beneficial to health in a scientifically detectable way. In his arguments he always uses “might” or “possible” rather than assertive words “must” or “invariably.” In his analyses of the quantitative studies, he is careful to avoid making rash claims. For example, he never claims—with apodictic certainty—that religious belief causes physiological changes. He further demonstrates scholarly prudence by identifying and accounting for factors that affect research. His distinguishing between “confounder” and “explanatory” factors in analyzing research data also demonstrates his discretion in selecting effective variables (130-1). His attitude of research adds credit to the cogency of his argument.

Despite these strengths, there are some weaknesses in the argument of this book: references to various studies seem redundant and the book is written for a limited audience. It is appropriate to present evidence in defense of the argument, especially in the chapters following Chapter 4. In these chapters, Koenig shows the mechanics of his argument that religion affects human emotions, activities, and social communities, and consequently religion affects human mental and physical states through these three affections. However, simply piling up evidence of the positive relationship between religion and health does not necessitate enhancing the convincingness of the argument. On the contrary, the argument becomes tedious and repetitious. Readers could lose patience.

It is a respectable endeavor to build a strong connection between religion and health from extensive scientific studies. But as a reader from a humanities background, I feel this book is just a restatement of a generally accepted standpoint, at least in humanities, that there is a positive connection between religion and health. However, in light of the author’s background, this book is probably written to the audience of physicians and scientists, who normally carry out medical treatments from an exclusively scientific perspective, in which religion is not included. It may be a revolutionary book for physicians. But for a humanist, who doubts science as the sole solution to treat human mental and physical problems, this book is by no means impressive.