Ryan, Debi, and Toren Cragun's Blog

Title:
Sloan, Richard P. 2008. Blind Faith: The Unholy Alliance of Religion and Medicine. St. Martin’s Griffin.

Rating:
8/10

Review:
Why look at the connection between religion and health care? Let me begin this review the same way the the book begins, by recounting the exploits of a Colorado surgeon:

“On February 22, 2004, the CBS Sunday Morning news program broadcast a segment about a Colorado orthopedic surgeon who prays with his patients. When does he pray with them? Not several weeks prior to surgery, for example, in an office visit when the decision to proceed with surgery is made. Not several days prior to surgery, during routine prehospitalization medical tests. Not even several hours prior to surgery. The surgeon “asks” if it’s “okay” to say a prayer when patients are gowned and on the gurney ready to go into surgery. Put yourself in the patient’s position. Would you feel free to say no to a physician dressed in surgical scrubs who is about to have your medical future in his hands, who is about to take a scalpel to your body?” (p. 3)

What Dr. Sloan didn’t add but I think drives this point home is: And what if the surgeon were a Hindu or Muslim, and not a Christian, which is what most people in the U.S. would automatically assume? Would you feel differently then?

So why did Dr. Sloan write a book about this? Because much of the “research” being done in this area is not scientific and the implications and recommendations are not ethical. Yet, those advocating including religion in health care seem to be winning this argument: the Bush administration just recently made it legal for all health care practitioners (i.e., doctors, nurses, secretaries, etc.) to refuse to perform health care activities they find objectionable on religious grounds and doctors are now being encouraged to evangelize their patients by conservative Christian leaders in the U.S. (p. 6). Richard Sloan’s book is a comprehensive resource for the large portion of the U.S. population that does not want to go to a doctor’s office only to be told that we should be going to church.

The book begins by arguing that the increase in animosity toward science (which actually followed a short-lived love affair with science after Sputnik launched in 1957) resulted from the New Age, self-help, and religious fundamentalist movements in the 1970s, 80s, and 90s. What Dr. Sloan doesn’t recognize is that these movements are, like all fundamentalist movements, backlashes against globalization and modernity, but he does recognize why some people oppose modernity: it’s complex and not readily understandable (p. 58). Of course, modernity also means a decline in authority and power for those who have traditionally wielded it: white men. Science doesn’t (any longer) put the opinions of white men above those of anyone else, leveling the playing field. The predominantly white and male leaders of fundamentalist religions feel threatened and attack science and modernity as a result. One of the victims in this battle is science, “Surveys commissioned by the National Science Foundation have asked respondents to explain in their own words how to study something scientifically. The answers suggest that about two-thirds of all Americans do not understand what it means to approach a problem scientifically” (p. 47). Along with the decline in science advocacy is an increase in reverence for subjectivity at the expense of fact: people feel like their opinon, regardless of how ill-founded or illogical it is, should be respected (pp. 47-48). The ethos of “feeling validation” is pervasive enough to serve as the entire shtick of Emmy Award winner Stephen Colbert. Colbert’s reductio ad absurdum portrayal of this ethos via his rants against “facts” and “the truth” has landed him a wide audience (most of whom realize it is an act, like I do). This ethos is, of course, inimical to science, which does not respect feelings.

Another contributing factor to the pervasiveness of religion in health care is the media, which knows that religion sells, “There is little doubt that in the media, stories about religion sell. The Newsweek Education Program Web site reports that in 2001, the magazine’s issue with the cover story on Mormons sold 240,000 newsstand copies, in contrast to the issue with the Sopranos on the cover, which sold 158,000. In 2002, the issue with the cover story on the Bible and the Koran sold 203,000 copies, while the issue with the cover story on Silicon Valley sold only 90,000 copies. The site reports that cover stories about religious matters sell more issues of a magazine on the newsstand – in fact, they’re generally among the top issues for the year” (p. 64). Thus, whenever a study, regardless of how poorly it was conducted, comes out drawing a connection between religion and health, it receives top billing by the media.

In practical terms, what does this mean? Well, let’s ask this question another way: Do you, the reader of this review, think that religion makes you healthier? Dozens of news stories are published every year suggesting as much. But what does the evidence actually show? Well, it depends on the specific claim that is made. But unlike those advocating a close affinity between religion and health care, Dr. Sloan reviews the evidence (mostly) objectively. Dr. Sloan uses a summary of research findings from one of the better studies published on these connections (Powell et al. 2003) as the launching point for his review of the literature (see table below). The second column summarizes the findings of Powell et al. (2003) from page 139 in the book (the article is available online here). The third column summarizes the findings based on more recent research, Dr. Sloan’s review, and my interpretation of his review and the literature I have read.

So, based on the second column in the table, it looks like maybe religion makes you healthier. Again, the details and nuances matter. Dr. Sloan illustrates that even the review by Powell et al. in the American Psychologist (a reputable journal) is misleading. Based on their review, religion and spirituality clearly do not: protect against death, disability, or the progression of cancer and they do not improve recovery from acute illness. There is also no good evidence that religion protects against cancer or helps people cope. But what about the other possible claims?

Let’s begin with religious service attendance. Does religious service attendance protect against death? Indirectly, maybe. Directly, absolutely not. Early studies examining this connection failed to control for one obvious factor: sick people can’t go to religious services regardless of whether or not they want to. So, highly religious sick people were being counted as “not religious” because they didn’t go to services. Anyone else see the flaw? Thus, when comparing benefits of religious service attendance, it appeared as though those who went were healthier and lived longer. But this is an inherently flawed way of measuring the relationship: of course those who attend are healthier and live longer, that’s why they are able to attend. The causal argument was reversed: attendance doesn’t increase health (directly), healthy people are the ones who attend. When you control for whether people would attend, most of the difference disappears (p. 93). There is still a very small health benefit to attending religious services, but it comes from having a strong social network, not from being at church. You can get the same benefit from getting together weekly with friends to play cards.

What about religion protecting against cardiovascular disease? Again, details are important. If you just measure the religious against those who are not religious (depending on how you measure this), you’ll probably find some differences and the religious will seem healthier. But if you control for lifestyle factors like smoking, drinking, promiscuous sex, etc. the difference disappears. In lay terms: If you have two people who do not smoke, drink alcohol, have promiscuous sex, and who regularly exercise, if one is religious and the other is not, there will be, on average, no difference in their health. Religion doesn’t make people healthy, lifestyle choices and behaviors do. So, indirectly, religion may provide cardiovascular benefits if it encourages a healthier lifestyle. But it is not religion that does that, it is the indirect benefit derived from a healthier lifestyle that does it.

What about being prayed for? Turns out a few years after the Powell et al. paper was published an authoritative study on intercessory prayer (that’s what it is called when you pray for someone) was published (Benson et al. 2006). In that definitive study, those who were prayed for didn’t do any better than those who were not. And those who were told they were being prayed for did worse (being told they were being prayed for probably led them to believe they were sicker than they actually were). Ergo, intercessory prayer is completely ineffectual.

In summary, religion has, at best, indirect benefits to health. But this hasn’t prevented advocates from fudging the data to suggest that religion improves health. One well-known study that claimed praying improved AIDS patients’ health (Targ et al. 1998) was so flawed as to almost be humorous:

“When Targ and her colleagues began the study, their aim was to see if the prayer treatment could have an impact on mortality. However, during the course of the study, the researchers were blindsided by the development of the then new antiretroviral therapies that revolutionized the treatment of AIDS. As a result, only one of the forty patients in their trial died, making it impossible to determine whether prayer had an impact on mortality. The researchers then sought to determine if the prayer treatment influenced some of their secondary outcomes such as physical symptoms, quality of life, mood, and counts of immune cells. It did not. Only after they analyzed length of stay in the hospital and physician visits did they find that the treatment and control groups differed in the predicted direction: the prayer group had shorter stays in the hospital and fewer visits to doctors… after the researchers discovered the group differences on length of stay and physician visits, they were informed by another physician that these variables were not very interesting, because whether or not patients had health insurance heavily influenced these outcomes. Not surprisingly, patients with insurance were more likely to stay in the hospital longer and have more doctor visits… Following the recommendation of this physician, Targ and colleagues then sought to determine whether their two groups of patients differed on twenty-three AIDS-related illnesses that had been identified in a very recently published paper. Unfortunately, these illnesses had not been measured in the original study, so the researchers, after already knowing which patients were in the treatment and control groups, went back to the charts to collect information on them. It was this information that they presented in their Western Journal of Medicine paper. There was no mention of the failure of distant healing to influence many of the original measures. Nor did the researchers mention that they had assessed AIDS-related illnesses after knowing which patients were in each group” (p. 98).

This approach to “research” is called the “sharpshooter’s fallacy” and is very common in the literature that claims religion improves health: you look for any possible relationship until you find one, then claim that one exists. How is this a “sharpshooter fallacy”? The sharpshooter fallacy is when you draw the bullseye after you shoot the gun. You can’t miss if you change the target’s location after you start. And that is precisely what many of these studies do. In fact, the leading name in most of this “research,” Harold Koenig, has published a massive book (Handbook of Religion and Health) that is filled with studies like this, most of which he proceeds to gloss over or misinterpret completely. Here’s Dr. Sloan’s take on the book, “Ironically, the great strength of the Handbook is also its downfall: because of their thoroughness, Koenig and colleagues have assembled the most comprehensive list of research studies thought to prove the health benefits of religious activity. What they have done instead is to show us definitively how incredibly weak the evidence actually is” (p. 137). Dr. Sloan actually reviews all of the studies in just one chapter of the book and illustrates that they do not show what Harold Koenig claims in the book; they aren’t even close.

So, the evidence, when accurately interpreted and evaluated, indicates there are virtually no benefits from religion directly. But there are additional problems with advocating the inclusion of religion in health care. For instance, when you claim religion can cure people of illnesses, people decide not to turn to the health care system, “about 25 to 30 percent of patients who used prayer for chronic conditions or cancer were not seeing a physician. For patients with psychiatric conditions, 90 percent of those using prayer were not seeing a mental health provider. Presumably, they relied solely on prayer because they thought it was sufficient to treat the condition and no conventional medical care was required” (p. 189).

Another problem with advocating religiosity or spirituality “assessments” by doctors is that doctors have no expertise in this area. They receive virtually no training in religion and are no more qualified to discuss religious matters with their patients than they are qualified to discuss quantum mechanics. This is especially true if their patients belong to minority religious groups. Doctors are experts in what they are trained in, nothing more. They have no business dispensing religious advice (p. 196). Additionally, if doctors spend their time discussing religion, what are they not doing (p. 219)? Would that time be better spent discussing healthy lifestyles? Or addressing other concerns of patients? Patients actually think so; 47% of patients want no discussion of religion or spirituality with their doctor; 3% want less (p. 236). Additionally, when asked who their first choice would be to discuss religious and spiritual matters, only 2% of patients said their physician (p. 237). Patients go to doctors for medical care, not religious proselytizing or to worship.

One area where I actually disagree with Dr. Sloan is over whether we should even be studying these issues. Dr. Sloan seems okay with studying whether or not a general religiosity improves or worsens health outcomes, but he does not advocate asking which religious groups are the healthiest (p. 182), as the outcome will always result in bias against one group or another. I agree with Daniel Dennett on this point: if the religious are going to make claims about the benefits of their religion, they should be willing to subject those claims to empirical scrutiny. If Catholics, Protestants, Muslims, Buddhists, Mormons, etc. believe they are the healthiest people, they better be able to show me the data. And if they can’t, then they should stop making such claims. If it turns out that some religious group has some key to health, I want to know. It’s unlikely that it has anything to do with the religion, but perhaps they advocate a particular lifestyle that correlates with improved health outcomes. That is worth knowing.

In the end, Dr. Sloan advocates religious privatization: be religious, use religion to cope, talk to your priest or pastor, etc., just don’t combine religion and health care. I don’t really disagree with him. In fact, I do think having chaplains in hospitals makes sense, so long as they are trained to be culturally sensitive and ecumenical. If people find comfort in religion (some do; others actually end up doing worse, medically, because of their religion), then why not give them some support in that. But doctors and other health care practitioners have no business discussing or advocating religion.

Overall, while a bit repetitive and long-winded at times, Dr. Sloan’s book is a long overdue skeptical look at the claims that religion has positive effects on health. I highly recommend it.