Sarkar and Seshadri have presented an interesting paper in this issue on the ethical approach that a physician should take when faced with requests for faith healing (1). The paper describes four approaches that the physician can take. These are rejecting the request, keeping oneself detached from the issue, endorsing the request and trying to understand the practices concerned so as to make a reasoned decision. This commentary attempts to explore the issue of faith healing further, from the point of view of clinical care. It shall discuss five important dimensions which can supplement the arguments by Sarkar and Seshadri. These are the concepts of faith, spirituality and religion and faith healing; the difference between cure and healing; patient-centred care; the various factors influencing a doctor’s response to requests for faith healing; and finally, the ethical issues to be considered while making a decision. Before launching into the discussion, it should be made clear that this commentary refers mainly to those faith healing practices which are not overtly harmful, such as prayers, and wearing rings and amulets.

Faith, spirituality, religion, and faith healing

Faith, spirituality, beliefs, and religion are words which are often used interchangeably. However, each word has a unique meaning. Faith is the inner search for purpose or meaning in life. It is a strong unquestioning conviction that “there is something more than just me”. The concept of faith is a universal one, not necessarily related to God. Even artists who are atheists and want to leave behind a legacy through their art have faith in the “more than just me” that is represented by their art. Spirituality refers to the object of faith (God, nature, the supreme power, art, science, etc.) and all the efforts made to connect with the object of faith, such as prayers, trekking, painting or singing. In other words, spirituality is the compass used by people to guide them towards their faith. Religion is the way of life of a community which shares common beliefs, common spiritual pursuits and a common faith. It is clear from these definitions that faith, spirituality and religion are strongly interrelated (2).

Many studies have demonstrated linkages between faith, spirituality, religion and health. A few observational studies have linked prayers with a reduction in overall mortality, and in deaths due to cardiovascular complications and cancer. Spiritual pursuits have also been demonstrated to slow down the progression of cancer and hasten recovery from acute illness. There are also some studies which have shown that prayers for patients can speed up their recovery from acute illnesses (3). Religious practices have also been associated with overall mental well-being (4). Most of these studies, however, are weak, confounding and riddled with biases. A systematic review of the effect of prayers for distant healing did not support the hypothesis that such prayers have any specific therapeutic effect (5). Though there is only weak evidence that prayers and faith-based practices have a therapeutic effect, the psychological advantages of such interventions cannot be denied (6).

Faith healing is a method of treating illnesses through the exercise of faith rather than medical methods. Faith healing is usually practised through prayers to gods and deities. All religions have their own faith healing practices. Several researchers have attempted to establish the effectiveness of faith healing practices. Two randomised controlled trials in the USA, which investigated intercessory prayers and their effect on the recovery of patients admitted in the coronary care unit, revealed that the group who were randomised to the prayer had significantly better scores on a composite index of course of illness during hospital stay (7, 8). Both these studies were limited by the fact that a thorough adjustment for confounders was not done and blinding was not possible. The outcomes that showed a significant difference between the two groups were subjective parameters. Though these facts weaken the argument for the strength of the effects of prayer, these studies show that there is a possible association that needs to be explored further. Several explanations have been proposed for the effectiveness of faith healing. These include psychological benefits, a better response to stress, healthier coping mechanisms and the activation of the immune system. Psychoneuroimmunology and the placebo effect have also been put forward as explanations for this association (9). However, one of the important reasons why modern medical practitioners hesitate to discuss faith healing with patients is the paradigmatic difference in the approach of modern medicine, which is focused on cure, as against religious and spiritual practices, which are focused on healing. It is important to understand the differences between cure and healing in the context of medical treatment.

Healing versus cure – the semantic dichotomy

Over the years, the outcome of medical endeavours has gradually come to be viewed as “cure” rather than “healing”. In historical times, medicine was considered a “healing” profession. With the advances in science and developments in medical technology, the biomedical scientist–physician has become a curer rather than a healer. The biomedical model lends itself to an objective examination of the organs, systems and their functions, attributes diseases to the observations made and attempts cures that are specific to diseases. This approach tends to distance itself from the holistic psychological, emotional and spiritual disturbances associated with diseases.

As for healing, the anthropological literature considers the healing process as a response to illness and classifies it as scientific and faith-based. It also explores the various faithbased healing processes in the western and eastern cultural contexts (10). The psychology literature looks at healing as “a process in the service of the evolution of the whole personality towards ever greater and more complex wholeness” (11). Nursing literature defines healing as “the process of bringing together aspects of one’s self – body–mind–spirit – at deeper levels of inner knowing, leading toward integration and balance, with each aspect having equal importance and value” (12). Healing is a process of transcending suffering in the physical, psychological and spiritual planes (13). Thus, the narrow biomedical concept of cure should be clearly distinguished from the more holistic concept of healing, which encompasses the physical, mental, social and spiritual.

There is a strong division today between the physician’s role as a “curer” and the nurse’s role as the “carer”. These roles, however, are slowly merging and physicians are increasingly required to take on holistic caring roles. In this context, a more open dialogue on spiritual and faith-based healing becomes essential. Apart from a focus on cure, the biomedical model of health places the physician at the centre of the treatment process. This approach has led to a systematic distancing of patients from doctors, as well as to rising healthcare costs because the physicians who are now at the centre of the treatment process place more emphasis on the disease and its cure rather than on patients and healing them. In an attempt to “cure” patients, they order expensive investigations and treatments, which lead to rising costs of healthcare without paying attention to “healing”. An emerging concept that is radically changing this approach is patient-centred care.

Patient-centred care – focusing on the patient

The global discourse on patient-centred care has picked up over recent years. Such care is seen as the ideal, cost-effective and meaningful way of delivering clinical services. Patientcentred care is defined as care which is respectful of and responsive to the individual patient’s preferences, needs and values, and which ensures that the patient’s values guide all clinical decisions (14). The fundamental tenet of such care is determining what matters most to a patient. When the patient is placed at the centre of care, there is an increase in the patient’s level of satisfaction, an improvement in clinical outcomes, and a reduction in unnecessary diagnostic tests, hospitalisations and treatments which, in turn, brings down the overall cost of healthcare (15). The process of healing is more important than cure itself because it encompasses care, concern, the involvement of the patient, shared decisionmaking, and psychological, spiritual and emotional support, all of which the patient needs, appreciates and absorbs to heal. With the emerging evidence of a relationship between faith, spirituality and health, evidence of the effectiveness of faith healing practices, consideration of the holistic concept of healing (psycho-socio-spiritual), and moves to place the patient’s preferences and requests at the centre of the care process, active engagement with requests for faith healing becomes essential. However, modern medical practitioners do not regularly discuss faith, spiritual pursuits, religious beliefs or practices with their patients. There are several reasons for this.

Factors influencing physicians’ approach to their patients’ faith and faith healing requests

The most important reason why physicians steer clear of discussing faith healing is their lack of knowledge of emerging research and evidence in this area. Approaches to alternative forms of healing do not form a part of the medical curriculum at any level. This creates a general disinterest in, and sometimes disbelief and disrespect for, the alternative forms of healing. Barring a few faith-based medical schools in India, religion is systematically dissociated from medical practice. Medical students are brainwashed into believing that medicine is purely a matter of science and that faith, spirituality and religion have no value in medical practice. These physicians feel uneasy addressing their patients’ requests for faith healing. Often, they end up analysing the biomedical benefits of such practices and making ill-informed judgments based on the analysis. For instance, from his biomedical perspective, the uninformed physician looks upon the practice of sprinkling holy water and holy ash on a schizophrenia patient as a faith healing practice, concludes that these have no effect on the dopamine levels in the brain of the patient and hence, are unlikely to produce an effect on the patient. This creates disinterest in and sometimes, disrespect for the faith healing practices. Yet another important reason for failing to engage with those who make requests for faith healing is a perception that such discussions are time-consuming and will waste valuable time during the clinical encounter. The physician’s assessment of the severity of a patient’s condition will compound this perception of lack of time. Another major reason why physicians distance themselves from faith healing requests is that they have strictly compartmentalised their work, in that they often feel that faith, spirituality and religion are beyond the scope of clinical work and that they are not required to do that work (16). All these factors may be modified to produce a more balanced approach to requests for faith healing. Medical students can be trained to have an open, albeit critical, approach to alternative forms of healing by increasing their knowledge and exposure to these systems. Educating doctors from the start of their training to be socially, culturally and spiritually competent physicians should be given priority in medical education reforms.

Making an ethical choice

However well trained and spiritually competent a physician may be, each request for faith healing comes with a unique set of ethical issues which the physician must consider before making the decision. Is faith healing the only option available to the patient at a cost that he/she can afford? Is the patient being pushed to resort to faith healing because of financial constraints, issues related to access to healthcare, social pressures or caste barriers? Is the request for faith healing a well-informed personal choice based on faith, spiritual practices, beliefs and values? It is important to answer these questions as they address the issue of healthcare inequities versus a well-informed autonomous choice. Trust in faith healers can often be a double-edged sword as it makes the individual who trusts vulnerable to exploitation. Is the faith healer exploiting the patient? This is another very important ethical question that arises while addressing requests for faith healing. Performing a risk–benefit analysis for faith healing practices may not always be possible. A spiritually and culturally sensitive risk–benefit analysis should be attempted. It is important to note that in the context of healing, faithbased practices are not value-neutral and their relative merits and demerits are contextual. The outright rejection or unquestioning acceptance of faith healing requests can communicate a lack of interest and involvement in the patient’s well-being. Active inquiry into the patient’s faith, spiritual practices and religious beliefs will help set the stage for a discussion on the request for faith healing. The clinical decision on faith healing should be a shared one, one in which the patient’s preferences and physician’s concerns are discussed openly. A respectful and interested approach to requests for faith healing may not produce miraculous cures, but will surely increase the patient’s faith in the process of healing.