It is refreshing to read an excellent resource authored by a well-informed,
well-read, committed, academician with ties to clinical medicine. Dr. Koenig’s
book is small enough to read in two sessions, and packed with enough information
to whet the appetite of any clinician irrespective of spiritual persuasion.
I was excited to review this book because I have been involved with this subject
for the past 15 years, both as a Pastor, and in my private practice of Medicine.
I was curious to see how he would capsulate what I had been practicing into
a book of 110 pages. To say the least, I was not disappointed.
Dr. Koenig’s introduction is succinct wasting no time preparing the reader
for the book’s contents. I have only one warning; if you read the introduction
you will purchase the book. The Introduction is so well written that the reader
is not left straddling the fence.
The Book is divided into seven chapters, namely:
1. Why include spirituality?
2. How to include spirituality
3. When to include spirituality
4. What might result?
5. Boundaries and barriers
6. When religion is harmful
7. Resources on spirituality and health
From the outset it is important to understand that this author comes from a
background rich in this subject. He has authored many clinical studies and authored
several textbooks, two this year alone.
The first chapter necessarily asks "why include spirituality?" Dr.
Koenig’s answer is patient centered. He presents data supporting the positive
health care outcomes of people as a result of their spirituality while supplying
the necessary caution in one’s approach. I agree with his statement; "religious
beliefs and practices, then, are used to regulate emotion during times of illness,
change, and circumstances that are out of patients’ personal control."
Dr. Koenig also gave a historical perspective in this chapter. He traced the
development of health care institutions and professions relating to spirituality
in medicine. As early as AD 370 a large hospital was set up in Turkey as a response
to Matthew 25:36-40; the profession of nursing came from the Catholic church,
first by the Daughters of Charity of St. Vincent de Paul, in 1617. A Lutheran
Pastor set up a nursing school in France in 1830 and Florence Nightingale, after
receiving a calling from God, sought and received training from the Daughters
of Charity and the Protestant deaconesses for nursing training. She is credited
with establishing the modern principles of nursing. Dr. Koenig continues by
showing the progress made in Psychiatry as a result of recognizing the importance
of spirituality in patient care. He concludes this chapter with both a summary
statement and an introduction to his next chapter. "Addressing spiritual
needs of patients is not new, either in the practice of medicine or in psychiatry.
How one goes about doing that in this day and age is the subject of the next
Chapter two addresses the issue of information gathering. Dr. Koenig introduces
several tools to assist the Physician. With each segment he discusses the importance
of recognizing two issues, namely: the patient’s sensitivity to the issue, and
the physician’s comfort zone. The tools serve as a method to carefully weave
between the two, enabling the Physician to obtain the history necessary to improve
the care of the patient. The Koenig, as well as all Physicians, recognize that
patient’s private lives are being invaded and perhaps limits are in order; however,
certain patient’s health outcomes are improved when the physician has knowledge
of their spirituality. Dr. Koenig makes it clear that spiritual inventories
must be individualized to patient condition and the depth of that inventory
may vary from patient to patient.
Recognizing the truth of the last statement the next chapter offers several
caveats that address the statement, when to include spirituality. This chapter
offers some useful tools that will assist the physician in initiating a spiritual
history. For the physician who wants to be sensitive to the patient’s needs,
without appearing "too religious," this chapter offers help. Dr. Koenig
lists the various points in the patient encounter where a history can be obtained
without appearing to be intrusive. Within the social history of a new patient
encounter, upon hospital admission, during a health maintenance visit, within
a hospice setting, are but a few places where this can be done. For the Physician
concerned with praying with patients and for the one that routinely prays with
patients this chapter discusses both the advantages and pitfalls of prayer.
Physicians are result conscious and it is this motivation that drives decisions
in therapeutic intervention.
This next chapter discusses the results of spiritual intervention. The results
of studies that deal with patient coping, compliance, and doctor-patient relationship
are presented. I was impressed with these statements:
"By asking about the patient’s religious beliefs in a respectful manner,
the doctor indicates a desire to understand an important part of who that person
is. If the physician then supports and encourages those beliefs, the patient’s
trust in the doctor may be amplified. If the physician goes so far as to actually
pray with the patient, then this will confirm even more that the physician can
Though this statement is a realistic outcome of such activity Dr. Koenig states
that caution must be made to avoid patient transference from a Physician-Patient
relation to a Physician-Priest, Patient relationship. There is only one situation
where a Physician-Priest, Patient relationship may be construed as acceptable.
I Pastor a Baptist Church within the city where I practice and several of my
members have chosen me as their primary physician. These patients call me Pastor
whether it is in the church or within the office setting. In my office setting
I represent their Physician-Pastor and in the church, Pastor. This unique circumstance
is the only one that I can site where transference has not occurred; the relationship
is already multifaceted.
Dr. Koenig discusses the negative consequences of spiritual intervention,
summarizing them in six bulleted points and presenting four legal case examples.
At this point I wrote another note in the margin. "I have discovered
that the physician must get to know the patient first. A Physician -Patient
rapport must be firmly established before initiating more probing interventions.
As physicians we invade people’s private lives enough. It is easy to treat the
biological aspects but tricky to get at the rest. Some patient’s complain that
we do not treat the whole patient; some like distance. The art is to distinguish
between the two!"
To distinguish between the two is to recognize those boundaries and barriers
to the process. This represents the purpose of chapter five. Dr. Koenig presents
the text of Hippocrates’ original oath, its amended version published in the
New England Journal of Medicine, the oath of Moses Maimonides, and of Pelligrino.
Each of these oaths represent the same principle; "do no harm" to
the patient. This chapter not only offers extensive explanations into those
boundaries and barriers that should be respected and broached with caution,
but also discusses methods by which the physician can overcome those barriers
that impede initiating a discussion into the spiritual aspects of patient care.
This chapter peaked my curiosity. I really wonder whether medical students are
being taught this aspect of patient care and if so actually using it. A survey
given to medical students each year of their schooling, through graduation,
and if possible residency, would prove to be a very interesting barometer of
physician comfort in this area. As physicians we are taught to know our limits
and not intervene where limited. Dr. Koenig’s recognition of this fact is the
background for the information presented in the next chapter.
Both sides of the argument are presented well. There are legitimate concerns
that intervention may introduce harm and there are concerns that the lack of
intervention may affect patient health outcome. As an academician Dr. Koenig
recognizes the need for further, evidence-based research in this area.
After reading this chapter I left with the realization that no randomized,
placebo-controlled study exists that evaluates the health status outcome of
a large group of patients in a community based setting where the intervention
was spiritual and the placebo was usual care. The chapter gives anecdotal information
and the sources of negative outcomes came from the media. I recognize that many
studies have been done in a variety of physical and psychiatric states; however
it was not the purpose of this chapter to introduce. It is my point of view
that this chapter served as an excellent spot to introduce the information.
The lack of it’s introduction indicates to this reader that research in this
area would answer the question, When is religion harmful?
If the reader has read the first six chapters he is hooked. Chapter seven
will be a welcomed delight. This chapter is pregnant with the synopsis of several
spiritual history taking tools. He summarizes the top research studies that
address spiritual intervention in mental, physical and social health. Next Dr.
Koenig gives an annotated bibliography of the major academic and nonacademic
books on the subject and concludes with websites where further information can
be obtained. The last section of the book lists the reference citations for
each chapter heading.
This book represents an excellent summary and springboard for any person interested
in the subject. In a matter of just a very few hours a wealth of information
can be gleaned from the book and the resources listed and summarized will only
peak the interest of the more interested. I highly recommend this book as reading
for all physicians and would certainly recommend it as part of any course on
medical ethics and/or required reading for any medical student.