In this issue’s feature, Michael Balboni and Tracy Balboni summarize the work presented in their new book, Hostility Towards Hospitality: Spirituality and Professional Socialization within Medicine (Oxford University Press, 2019). Tracy, a physician, and Michael, a theologian, explore the ways in which modern medicine neglects, and is potentially hostile towards, the humanistic concerns of paramount value in spirituality and religion. Their book proposes, among other things, that “both spheres (medicine and theology) become more whole through the light shed from the other.” (vii)
Within the experience of serious illness, empirical research reveals an indelible connection between medicine and spirituality—broadly defined as the way individuals seek and express meaning and purpose, and experience connectedness to self, others, the significant or sacred.  Spirituality, experienced individually and/or within communal, religious forms, impacts patient well-being, satisfaction with care, medical decision-making and medical care outcomes. However, evidence demonstrates the medical profession largely neglects the spiritual dimension of patient well-being and illness. Collectively this evidence demands reevaluation of how medicine interfaces with spirituality and religion. In the following we present a summary of our studies of this phenomenon and conclude with four recommendations for how medicine can better respond to patients’ spiritual experience of illness. Additional evidentiary support of our findings can be found in Hostility to Hospitality: Spirituality and Professional Socialization within Medicine.
Patient Experience of Serious Illness
Consider the evidence regarding how most patients encounter serious illness as a spiritual experience. A survey of 542 hospital patients in North Carolina found patients strongly endorsed religious attitudes and practices, with 65 percent of patients attending religious services at least a few times per month.  In another study of 100 terminally-ill patients at the M.D. Anderson palliative care outpatient clinic in Houston, Texas, 80 percent of patients reported being Protestant, the majority of whom reported high levels of spirituality and religiousness.  In a survey of cancer patients at the Saint Vincent's Comprehensive Cancer Center in New York, NY, 29 percent of patients attended religious services weekly, and 66 percent described themselves as spiritual (but not religious).  In addition to self-reported religiousness and spirituality, we conducted a study among Boston teaching hospitals that found 78 percent of patients considered spirituality and/or religion important to their cancer experience, 73 percent reported being spiritual, and more than half considered themselves both spiritual and religious.  In a multiregional sample of 230 patients, religion was considered important by 68 percent of terminally ill patients, the highest rates being among Blacks (89 percent) and Latinos (79 percent).  While religiousness and spirituality are affected by regional variation, taken as a whole, this data shows U.S. patients are highly spiritual and frequently religious. Data suggests that many patients interpret their illness through this spiritual lens.
There is also some indication that as people age and encounter serious illness, religiousness and spirituality increase.  Consequently, surveys of spirituality/religiosity among the general population will always underestimate the role of spirituality and religion in the context of serious-illness. There are no prospective studies following people as they transition from relative health to serious illness, so the size of any change cannot currently be estimated. There is limited evidence that suggests both higher levels of stress are associated with increased religiousness, and patients experiencing advanced cancer report significant changes in daily spiritual activities (e.g., prayer) after diagnosis (47 percent before vs. 61 percent after, ‹ p.0001). In a study of 108 women with gynecologic malignancies, 49 percent reported becoming more religious after diagnosis, with none reporting becoming less religious.  This has been termed the “foxhole” effect —a reference to the adage that there are no atheists in battlefield foxholes.  Freud thought this shift emerges out of a direct confrontation with, or heightened awareness of, one’s fear of death or hope for immortality. This effect does not necessarily explain the origin of religion, as Freud believed, but it is a dynamic that sheds light on why religion and spirituality become increasingly operational when physical health wanes.
Within the context of serious illness, a plethora of spiritual needs arise, from fear of dying or of being punished, to difficulty in finding meaning in illness, to searching for the presence of God. In our survey of cancer patients at Boston teaching hospitals, 51 percent of patients wanted help to overcome their fears, 42 percent in finding hope, and 40 percent in finding meaning.  In another study of 727 racially/ethnically and religiously diverse patients utilizing general medicine, cardiology, and neurology services at Duke University Medical Center, 79 percent reported having at least one spiritual need.  In a study at MD Anderson in Houston, 58 percent of advanced cancer patients reported experiencing “spiritual pain.”  Patients with spiritual pain had significantly lower self-perceived religiosity and spiritual quality of life. In a Boston-based study, 85 percent identified one or more spiritual issues with a median of four issues per patient among 14 spiritual issues assessed. Key spiritual issues among patients included: “seeking a closer connection with God or one’s faith,” 54 percent; “seeking forgiveness (of oneself or others),” 47 percent; and “feeling abandoned by God,” 28 percent. Surprisingly, among the 22 percent of patients who said that religion or spirituality was “not important” to their cancer experience, two-thirds had at least one spiritual issue and 40 percent reported four or more spiritual issues. We found that only 7 percent of all patients were consistently non-religious and non-spiritual. The results of these studies suggest that there is a high prevalence of religious/spiritual needs among patients facing serious illness, and that even among patients who do not consider themselves religious/spiritual, spiritual needs remain frequent.
Large majorities of patients turn to religion and spirituality to cope with illness.  Many find new meaning and purpose within serious illness, and some receive practical help through supportive spiritual communities.  This evidence demonstrates how spirituality and religion are important and prevalent within serious illness. But do spiritual experiences of illness substantiate a mandate to overcome the separation between medicine and religion? When combined with outcome measures, we believe they do. We turn to this next.
Spirituality and Religion and Measured Outcomes
Growing evidence gathered from the past two decades demonstrates that religion/spirituality is associated with quality of life measures, satisfaction, and utilization outcomes.
Quality of Life: In 1999, Brady et al. carried out a multisite, cross-sectional study of 1,610 cancer patients.  After controlling for other predictors of quality of life, higher patient religion and spirituality (R/S) was found to be associated with improved patient quality of life. Furthermore, among patients with a high burden of physical symptoms (e.g., pain), those reporting higher R/S had better quality of life scores than those reporting lower R/S. Likewise, greater patient religious coping and patient spirituality has been reported to be associated with better patient psychological well-being and overall quality of life.  Similarly, unaddressed spiritual concerns of patients are associated with decreased psychological and overall quality of life within advanced illness.  Recently hospitalized patients viewed “being at peace with God” and “freedom from pain” as the two most important elements of quality of life at the end of life.  In contrast, other studies have found associations between spiritual pain and adverse physical and emotional symptoms including increased depression, anxiety, and anorexia.  Moreover, in a multi-regional study of advanced cancer patients followed through death, patients who reported high support of their spiritual needs by the medical team at baseline had better quality of life near death.  These studies provide initial evidence that R/S plays a key role in the well-being of patients with serious illness and influences quality of life when facing death. Improving quality of life within serious illness must entail engagement by the medical community to support the spiritual lives of patients.
Satisfaction with Care: A cross-sectional study of data drawn from the University of Chicago Hospitalist Study found that patients who reported their spiritual needs were not being addressed by medical staff were more likely to negatively assess overall quality of care and be less satisfied with their medical care.  Similarly, a study of 542 patients seen for management of depression at Duke University Medical Center showed that patients reporting greater spiritual needs had lower ratings of satisfaction with care and lower perceptions of the quality of care.  While these initial studies do not prove causation, they suggest possible association that requires future research.
Decision-Making: Religious viewpoints and beliefs have been associated with a delay in seeking treatment for serious illness.  Additionally, religious factors are associated with patient and surrogate decision preferences such as desire for aggressive treatment  and wanting all measures to extend life.  Studies also suggest that religious communities support medical decision-making informed by religious beliefs. ,
End-of-Life Utilization: Patients reporting a high level of support of their spiritual needs by their medical teams (e.g., doctors, chaplains, nurses) have been found, as part of a prospective cohort study of 340 advanced cancer patients, to have a three-fold greater odds of transitioning to hospice care at the end of life as compared to patients receiving low spiritual support.  In the same study, high religious coping patients whose spiritual needs were well-supported by the medical system were five times more likely to transition to hospice and five times less likely to receive aggressive care during the final week of life. Hence, while high religious copers are more likely to receive aggressive care at the end of life as found in the Phelps et al study,  subsequent analyses suggests that medical system spiritual support reverses this outcome. In a follow-up report, the associations of spiritual care with medical care received at the end of life were found to impact end-of-life medical costs.  The medical care of patients whose spiritual needs were poorly supported cost on average $2,441 more in the final week of life than that of patients who were spiritually well-supported by the medical team.
These studies suggest that spiritual care in the medical setting—acknowledging patient spirituality/religion and addressing spiritual needs—impacts patient end-of-life outcomes. Religion and spirituality are not peripheral to the medical experience, but have measurable effects within several domains.
Medicine's Neglect of Spirituality
Evidence of the role of spirituality within illness and patient outcomes should serve as a trigger for the medical system to constructively respond to patients’ spirituality/religion as part of patient-centered and culturally sensitive care. Studies have found a majority of seriously ill patients view spiritual inquiry and engagement within the patient-clinician relationship as important, [13,25] appropriate,  and supportive. Notably, in a study of patients seen in the primary care setting, 67 percent wanted their physician to be aware of their spirituality/religion; however, most (78 percent) would not want discussions of religion/spirituality if it resulted in less time spent discussing medical matters.  Patient desire for spiritual interaction was also found to increase with increasing severity of illness.  However, few patients with serious illness are spiritually engaged by clinicians. [3 ,5,27] For example, patients in Boston indicated that they had rarely received any form of spiritual care from their physicians (6 percent) or nurses (13 percent) at any point in their cancer care. 
Many patients and their family members engage the larger illness experience, including medical decisions, through a spiritual/religious framework of values and meaning. In a mult-site study of 275 advanced cancer patients, 87 percent of patients endorses religious beliefs in the context of end-of-life medical care (e.g., sanctity of life, miracles) with 62 percent endorsing three or more.  The medical team’s frequent lack of recognition of this dimension of the illness experience is illustrated in a 2015 report from a multicenter prospective study of 249 audio-recorded family meetings with surrogate decision makers in the ICU. Though most (78 percent) surrogates considered religion/spirituality to be important, only 16 percent of conversations raised spiritual or religious concerns, and 65 percent were by the surrogate. Furthermore, after surrogates directly raised religious concerns about treatment decisions, fewer than 20 percent of physicians further engaged or asked follow-up questions.
The separation model in which medicine neglects and avoids spirituality/religion is reinforced by what Peter Berger called “plausibility structures.”  These are unstated assumptions rooted in particular social processes that legitimate socially held beliefs and practices, giving them a matter-of-fact quality. The assumption that medicine and spirituality should remain separate remains largely unquestioned throughout medicine, especially academic medical schools and teaching hospitals. Plausibility structures socialize clinicians to neglect or avoid patient spirituality and religion.
What are key beliefs that reinforce the separation of medicine and religion?
•Hospitals are primarily institutions of technology and cure rather than organizations aimed toward humanistic care.
•Physicians conceptualize themselves primarily as scientists, and secondarily as health managers, rather than primarily as healers attentive to the whole person.
•The human person is divisible according to material and immaterial; on an anthropological level, there is no direct connection between body and soul. Physical health and disease are not directly related to spiritual factors.
•Engagement of fear, finitude, and death are subjective domains, and better dealt with by others, including clergy and religious communities.
•Contemporary medicine is driven by bureaucratic concerns and secular factors including the market, science, and technology. Spirituality and religion cannot fit within this system.
Engaging the Gap
As empirical evidence mounts, medicine can no longer allow neglect of spirituality and religion to remain the status quo. Simplistic divisions between body and soul fail to account for patients’ experience of illness, or how medical decisions are approached by many patients. Dichotomous approaches fail to be patient-centered and are leading to costly gaps in the care of the seriously ill and those at the end of life, both to patients and the health care system. How then can medicine constructively and without defensiveness respond to patients’ spiritual experience of illness? We offer four brief responses.
1. Research: Clinician responses should move forward using empirical research as a critical tool. This requires that clinicians, spiritual/religious experts, and funding organizations partner together and invest in conducting rigorous research studies. Research needs include greater description of the patient experience of spirituality within varied cultural and clinical contexts (e.g. pediatrics, psychiatry, internal medicine, etc.) and exploration of how these factors relate to important medical outcomes such as quality of life and medical decision-making. Furthermore, research is needed to develop and test spiritual care interventions. Hypothesis-testing, increasingly sophisticated measures, peer-reviewed research, and medical-religious partnerships are a critical way forward to bridge the gap that exists in engaging patient spirituality and religion. While the field of spirituality and health is young, evidence and its clinical implications have begun to be noted. 
2. Training: A key structural change in the socialization of clinicians must include the incorporation of spiritual care training for physicians and nurses. Receipt of spiritual care training has been demonstrated to be the most powerful predictor of physician’s and nurse’s provision of spiritual care to the seriously ill.  If trained, even those who were not religious were far more likely to provide spiritual care to seriously ill patients. Even a minimum level of mandatory clinician training would likely help overcome biases sustained through a systematic silence.
3. Concerns for Patient-centeredness or Professionalism: In surveys there is strong agreement between patients and clinicians that within spiritual care provision neither should be made to feel uncomfortable or pressured to participate in a spiritual/religious conversation. [30,31] Furthermore, patients do not wish to put clinicians in the position of not being authentic to their beliefs.  Spiritual care should be patient-centered and appropriate to the professional role and training of the clinician. A simple minimal standard is that clinicians should be expected to ask each patient if and how spirituality or religion might be important to their illness.
•If the patient indicates that spirituality and religion are not important to them during the initial clinical history, then the clinician moves on.
•If the patient appears to be spiritually struggling, then with the patient’s permission, the clinician would help facilitate a chaplaincy visit or, where relevant, encourage the patient to see their local minister or other trusted community spiritual supporter.
•If the patient indicates that his or her faith is related to clinical decision making, then the physician must consider ways to sensitively engage the spiritual aspects of those deliberations, such as inviting the patient to involve his or her spiritual supporters (e.g. clergy) in medical decision-making.
There are many other factors conditioning how patient-clinician engagement around spirituality is sometimes more and sometimes less appropriate. Conditions of appropriateness include issues such as the length of relationship, degree of training and comfort with spirituality and religion, and spiritual/religious concordance; the degree of mutually shared understanding of tradition, beliefs, and spiritual practices. Within serious illness, there is no expectation that clinicians go beyond a minimal standard of spiritual inquiry. However, there are many additional reasons justifying greater discussion, or shared practice in certain circumstances, when patient and clinician are both comfortable.
4. Religious Partnership: Since the illness context is a hybrid of secular, sacred, and humanistic elements, it will be most effectively engaged when medical professionals and medical institutions partner with local religious communities and religious clergy. We argue in Hostility to Hospitality that future partnership is critical in caring for patients, body, and soul. Just as importantly, we contend that as medicine becomes increasingly dominated by market, technological, and bureaucratic forces, equally powerful forces like community spiritual/religious organizations will be needed to protect the personal and human aspects of compassion and care.
Follow the Evidence
Many years ago, we learned a valuable lesson from one of our academic mentors at Harvard, a self-described humanist and atheist. She taught us that medicine is always at its best when it follows the evidence, no matter where it leads. Our mentor championed aspects of our research that shined light on the positive impact spirituality and spiritual care can have on patient outcomes. When we asked her how she was able to steadfastly support that work despite her personal beliefs, she smiled and said, “For the sake of our patients, we follow the evidence.” For us, her advice gave us courage while studying and publishing empirical data that at times suggested religious factors had a negative effect on end-of-life outcomes. Research is increasingly able to successfully measure spiritual and religious factors in illness; there is sufficient evidence to demand that medicine similarly “follow the evidence,” and engage in constructive partnerships with the spiritual/religious resources of the patients, families and communities it serves.
Michael Balboni is a theologian and social science researcher at Harvard, and a minister at Park Street Church, Boston. Tracy Balboni is a radiation oncologist and at the Brigham and Women’s Hospital and the Dana-Farber Cancer Institute, and Associate Professor at Harvard Medical School. They are codirectors of Harvard’s Initiative on Health, Religion, and Spirituality.
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