For years I have been struggling to understand how prayer and healing are related. My thinking became more focussed as I became more knowledgeable about the science of clinical epidemiology. As I became more convinced that properly designed clinical studies should guide more decisions about establishing better medical treatments, I began to ask myself: Is prayer a treatment intervention like others that I had learned about and used for treating cancer? If so, can it also be subjected to scientific study, using the same tools I had acquired to study what the best chemotherapy or radiation therapy should be? At times, I was challenged to reassess my growing belief that results from randomized trials provided the best evidence to convince myself and my patients that a certain treatment was the best for their situation. What should this mean in my counselling to my patients with cancer? Should I incorporate prayer into my practice and if so, how? I knew prayer was fundamental to my faith and to my daily walk with God, but could it actually lead to improvements in the outcomes of even my sickest cancer patients? Indeed, was it my responsibility as a reformed Christian and physician to offer prayer as a therapeutic intervention?
My worldview comes out of a belief that God through Christ has redeemed our entire fallen and broken world, and in this context I should resist the traditional biomedical paradigm. I should see patients and treatments beyond their biochemical and physiological aspects and embrace a more all-encompassing view of healing and restorative principles. However, would I be overstepping my sphere of expertise and authority by praying with patients and asking probing questions about their faith life as their cancer steadily eroded their health? And how was prayer to be distinguished from the growingly popular search for individual spirituality? Last year, I had attended a conference at Wheaton College on Health, Healing, and Spirituality where I met and heard Dr David Larson, a Christian in the episcopal church, speak on his studies of the effect of spirituality on health outcomes. Early this year, an article appeared in one of the most respected journals in medicine, the Annals of Internal Medicine, by Larson and associates from the National Institute for Healthcare Research and the Center for Biomedical Ethics at Case Western Reserve University in Cleveland. The article reviews studies that seemed to indicate that "…statistically significant evidence seems to support a salutary association between …single items of religion and morbidity and mortality." The article goes on to say that "…credible studies indicating health benefits associated with religious spirituality have been published in the best clinical journals." And, finally, they conclude "Research is showing that a patient's spirituality can play an important role in ameliorating the sequelae of severe illness.". Some studies seem to suggest that it is not the specific religion that is most important, but rather the sincerity and intensity of the spirituality that counts; Jews, Muslims, and Hindus may reap similar improvements in pain relief, emotional, and relational well-being according to some studies. However, the authors then seem to turn around and caution the enthusiastic practitioner to be ethically sensitive to the "…distinct spheres of activity to ensure competence and boundaries.". The boundaries between coercion and sincere prayer with a patient can be blurred in a society hypersensitized to patient vulnerability and sometimes reprisal in the form of litigation. One respected Muslim surgeon goes on to recommend that " Physician-led prayer is acceptable only when pastoral care is not readily available, when the patient is intent on prayer with the physicians, and when the physician can pray without having to feign faith and without manipulating the patient.". Following these guidelines, prayer would require informed consent in many institutions.
My interest in this topic found an unexpected forum recently in a gathering of about 20 Christian health professionals including physicians, medical and surgical residents in training, physiotherapists, medical students, and others. The leader of the discussion was a soft-spoken resident in orthopedic surgery who had clearly taken time out of a very busy surgical resident's schedule to find three studies testing the efficacy of prayer. We were to split up into small groups; each group would study and critique one of the studies and report their findings to the whole group after about 20 minutes. The resident had done his homework well, it seemed. All present were involved in some professional way or another with McMaster University, an internationally recognized center of excellence in the study of clinical trials methodology (the discipline interested in finding the most scientifically rigorous methods to ask different clinical management questions). Everyone seemed to confidently support the choice of three randomized trials. After all, if treatments are randomly allocated to patients, did that not reduce the chance of inherent bias such that the only factor, known or unknown, that could affect the outcome would be the assigned treatment? Science meets faith! I looked forward to a rewarding evening with brothers and sisters in the faith.
The most scientifically rigorous study presented was that of Dr Randolph Byrd, published in 1988. Three hundred ninety-three patients in a coronary care unit were randomly chosen to receive or not to receive prayer from born-again Christians from around the United States. Armed with the patients' names and clinical status, these Christians offered prayers daily until hospital discharge for each patient assigned to the prayer cohort. The other cohort did not receive prayer by an assigned intercessory prayer group. The study was double-blind, meaning neither the patients nor their direct care givers were aware of which group they were in; i.e., whether they had been assigned for intercessory prayer or not. Multiple clinical variables and complications were recorded; the more interventions needed to treat complications, the less successful was deemed the recovery. Overall, the study showed that patients in the control group suffered almost twice the complication rate compared to those for whom intercessory prayers were offered. The result was statistically significant, meaning the probability that the result was a fluke and did not reflect the truth about the question was less than 5%.
Another more poignant study involved children with leukemia. Only 18 subjects were in the study; ten of the children were assigned to receive prayers daily for 15 months by a church in Washington, DC while the other 8 children were not. While the patients and treating staff were blinded to the treatments, it is unclear if the allocation of treatments were randomly assigned. At the end of the 15-month study, 8 of the 10 children for whom were alive, while only 2 in the other group were still alive. A third trial involved 120 patient with hypertension who remained on their high blood pressure medication and diets during the study. Three treatment groups were studied; one group received the laying on of hands once weekly for 15 weeks by trained healers in this procedure, one group were offered positive intention thoughts by trained healers in a room next to the room patients were in, and the third group received no prayer therapy. In this study, blood pressure was lowered to a similar degree but the group who experienced the laying on of hands had a significantly greater sense of well-being that those in the other two groups.
As each small group took its turn to report, a spokesperson methodically went through the results, reviewing the strengths and weaknesses of the study design, and in the end decided that something seemed to be positively affected by prayer. The growing enthusiasm in the room was palpable. I soon found myself getting flashbacks to my youth. What a wonderful Biblical proof it would be, I used to think, to find the remnant of Noah's ark on Mount Ararat, as some have claimed is possible or even likely. In a similar way could we prove to the world that prayer works?
Then, as the group was wrapping up the last study, I asked a question that unintentionally changed the tone of the discussion: are we sure, I asked, that prayer is susceptible to scientific scrutiny? Can we assume that the results of prayer follow the same laws or norms for creation that allow other interventions to undergo scientific assessment? After all, we believe with considerable confidence that the right vaccine will prevent polio, a once incurable and often debilitating scourge. What laws does prayer follow such that our methodology which is based on probability principles would allow us to reproducibly verify and to generalize the results to a certain patient population? If studied with the proper clinical trials, can prayer be offered to patients so that, with confidence, I can assure the patient that prayer has an an X percent chance of adding to his or her quality of life, feeling of well-being, or of extending that person's life by weeks, or even years? Or, is this thinking really a trap of our scientific paradigm in late 20th century medicine; i.e., can science really lead us to the truth about our faith life in the same way that it can lead us to the truth about our physiological, biological, and physical well-being. Whether my hypothesis was true or not was not as important to me as the fact that the entire discussion that evening assumed that prayer was an intervention like an herbal medication or high blood pressure pill taken from the medicine chest. Just because someone decides to use the best scientific method of the day to test a hypothesis does not necessarily mean that the question is answerable by science.
But then I raised more disturbing questions to the group; what if the result of a prayer study was resoundingly negative? What if there was no absolute difference in the degree of pain experienced by the subject with arthritis, for example? What if there was a difference but it was not statistically significant? Furthermore, perhaps more studies had been done, were found to be negative but were not published out of concern for the negative impact on society's perception of prayer and Christianity (publication bias). If we would treat the results like other interventions, what would be our options as caregivers in translating the results into changes in practice? If there was no difference in the incidence of death from meningitis in the study of a new antibiotic compared to an existing standard antibiotic, then we would likely discard the new one, stay with the old standard, and test something else. If a clinical trial showed that the number of deaths from leukemia were no different whether a preassigned group offered prayer or not, what would we do with prayer? Some Christians believe that such a result could only mean that we have not prayed hard enough or sincerely enough. If that were true, why are true, sincere Christians not immortal? Have martyrs for the faith died because they did not pray sincerely enough in the end? What could we say about prayer to the already skeptical non-Christian colleague who doesn't believe that prayer helps? Do we admit that it does not work? Or do we start self-critiquing the study design and find a methodological way out by acknowledging scientific ineptitude? I think we must consider that prayer, by its nature, may not be understandable in terms of science.
I continue to be troubled by what I read concerning this topic. In some ways, science reduces prayer to the level of generic spirituality. For example, Dr Larry Dossey has tried to explore the possible mechanisms of prayer by applying models of quantum physics and proposing that intercessory prayer is a manifestation of the essential unity of human and divine consciousness that is not limited to space and time. In this sense, he goes on to say, nondirected prayers (e.g., "May the best possible outcome prevail") may be more effective. The idea of generic spirituality has become increasingly popular in our culture and Christians have seen this as a historical opportunity to speak out about their faith in a more accepting climate. But I also think that Christians must think carefully with one eye on the Bible and the other eye on the audience. We must first understand the distinction between biblical directives about prayer (ie, trust in God and selfless service to God and our neighbor) and the human desire to have personal needs met on demand. If the latter prevails, the exploration of spiritual needs will be at best narrowly focussed and confined to crisis situations. Few would deny that prayer in our day is often most sincere and specific when a crisis has occurred, not uncommonly related to failure of health. The Bible does not teach that we confine our prayers to crises; rather, we are asked to pray continually, that we may not falter or stray from a life in the Lord. Pray is multifaceted; we pray to praise God, to ask forgiveness, to acknowledge his power, patience, kindness, and righteousness. We pray to offer thanks. We pray that God's Kingdom be accomplished on this earth and on the new earth. We are His instruments of that accomplishment and, while we can ask for forgiveness or a reprieve from an impending disaster as did our Lord before he was crucified, we must never forget that the important result is not that we can predict the probability of getting what we want. Rather, a successful and effective prayer teaches us to walk humbly with our God.
In fact, there seems to be a tension in this regard for at least some Christians who are studying prayer with randomized clinical trials but also acknowledging that answered prayer does not always mean answered in the way we hope or want at the time. Dale Matthews, who I mentioned earlier as the principal investigator of a randomized trial testing the efficacy of intercessory prayer, says in his book The Faith Factor: "Spiritual maturity involves trusting that God will answer our prayers according to our real needs as he sees them, and not as we, with our limited vision, see them…. Our petitionary prayer should not be an attempt to control God but, rather, to relinquish control of our problems and to acknowledge God's presence and activity in our lives. After all, the ultimate goal of prayer is not to get our needs met or to get what we want; it is to draw us nearer to God."
Will Christians continue to explore the outcomes of prayer on a population basis? Matthews feels that we must continue with clinical studies to answer questions such as these:
1) What method or type of prayer brings the best results for patients who pray for their own recovery from physical illness?
2) How do the frequency and duration of prayer affect medical outcomes? Christ gives us some teaching on the duration as well as location for prayer: "But when you pray, do not be like the hypocrites, for they love to pray standing in the synagogues and on the street corners to be seen by men…they will receive their reward in full. When you pray, go into your room, close the door and pray to your Father, who is unseen. Then your Father, who sees what is done in secret, will reward you. And when you pray, do not keep on babbling like the pagans, for they think they will be heard because of their many words. Do not be like them, for your Father knows what you need before you ask him. (Matt. 6:5-8)
3) Do patient attitudes regarding the importance and effectiveness of prayer influence health outcomes?
4) How can the effectiveness shown in studies of patients with certain diseases be extrapolated to other diseases? Or, do we require studies in other diseases to "hold up" these initial positive results?
5) More longitudinal studies should be done to answer questions like "Do those who attend church weekly develop fewer cases of cancer than those who attend once a year or less?" In fact, some studies have already begun, such as a 15-year study comparing the mortality rates of members of religious and non-religious kibbutzim in Israel.
As I completed this presentaton, I noticed a front page story in the Life section of the June 29, 2000 issue of US TODAY with the title: "For seniors, prayer good for body as well as soul". The study was a prospective cohort study of 4,000 senior citizens who were asked about health problems and whether they prayed, mediated or read the Bible. The study authors reported that seniors who never prayed had a 50% greater risk of dying during the 6-year study period compared to those who prayed at least once per month. Those who prayed more often had no additional benefit. While I rejoice that this type of article is now acceptable to print in the newspapers of our society, the article also demonstrates the struggle with interpreting such studies. "The findings" says the article, "could bolster a belief in a divine being. [But the study author] sticks to the scientific explanation….Prayer and meditation are known to reduce stress and thus can dampen the body's production of damaging stress hormones such as adrenaline." A university psychologist and critic states: "…the study and others like it, promote the harmful notion that prayer can protect against illness and death. Yet people who get sick despite prayer may blame themselves for not praying hard enough…'That's not good medicine or good science'".
Do not misinterpret me. I am not speaking against the need to recognize the spiritual needs of patients with illness, in my case those with cancer. Rather, I am sounding a note of caution. We must be careful not to secularize our idea of spirituality by assuming it is an end unto itself. Similarly, we must not look to prayer as a generic tonic that is predictable and generalizable to a diverse group of people with common ailments or needs. We as Christian health care providers must take advantage of a new climate of awareness and need that goes beyond a narrow and oppressive biotechnical, stimulus-response mentality. We must proclaim the Lordship of Christ among the well and the sick, among the poor and the wealthy, among all that are God's creatures, and seek the truth of His Kingdom. But we also must be careful not to use the tools of science in such a way as to reduce the meaning and wholeness of prayer in the process. I am not convinced that prayer can be handled scientifically like we can handle other aspects of creation where we dissect and focus on a small part of a whole, then try to reassemble it with new insight and meaning of the whole. Perhaps this can be done but I am concerned that the present methods have more pitfalls than insights into the meaning of prayer in the context of the restoration of health.