Letters

Spirituality and clinical care

BMJ 2003; 326 doi: http://dx.doi.org/10.1136/bmj.326.7394.881 (Published 19 April 2003) Cite this as: BMJ 2003;326:881

Placebo or not—we may never know

  1. Daniel R Nethercott, senior house officer, palliative medicine (danielnethercott{at}hotmail.com)
  1. Holme Tower, Marie Curie Centre, Penarth, South Glamorgan CF64 3YR
  2. Worcestershire Acute Hospitals NHS Trust, Worcester WR5 1DD
  3. Addictive Behaviours Centre, Birmingham B4 6SX

    EDITOR—I agree with Culliford that knowing your patients better makes for a better therapeutic relationship.1 Often—for example, in terminal care or when physical measures do not have an impact on any disease—being able to relate in “wider” terms can increase the potential for healing. But I disagree with Culliford on the question of methodology.

    Most religions and other arenas of spirituality use ritualised gestures, incantations, prayers, symbolism, and rites. Unless you believe that these processes have effects through a perceived extracorporeal being, power, or energy, the effect is presumed to come from within patients themselves. But the placebo effect is inherently based on its own camouflage. Once you know you're taking placebo then the magic is lost.

    The entire effect is dependent on your “faith” in the procedure. Although I might deliberately use the placebo effect in my pharmacological treatment of patients, is it not an unethical deceit for me to portray a facade of spirituality for their benefit when I don't believe it myself? If that is true then what is Culliford suggesting? Might it be that my deficiencies as a non-believer translate into deficiencies as a doctor? Perhaps I don't really want an answer to that.

    Footnotes

    • Competing interests DRN is a practising atheist.

    References

    1. 1.

    Spiritual care based primarily on happiness is dangerous

    1. Matt J Hawker, senior house officer, ophthalmology (mands{at}freenetname.co.uk)
    1. Holme Tower, Marie Curie Centre, Penarth, South Glamorgan CF64 3YR
    2. Worcestershire Acute Hospitals NHS Trust, Worcester WR5 1DD
    3. Addictive Behaviours Centre, Birmingham B4 6SX

      EDITOR—Culliford's editorial reflects a resurgent interest in spiritual aspects of healing through discontent with a purely materialistic world view.1 Our culture does not believe in a pure scientific reductionist model that says we are made solely of a chemical structure (witness the Princess Diana experience and films such as Sixth Sense and Star Wars). Our experience tells us there is a greater depth to life, and I welcome Culliford's recognition of this as central in healthcare provision. However, a case for spiritual awareness and treatment based primarily on outcomes of happiness and wellbeing is dangerous. Leading patients to believe that spirituality brings happiness may cause upset through disappointment or more seriously propound disregard for spiritual truth—“It doesn't matter what you believe as long as it makes you happy.” Of far greater importance is “Is it true or not?”

      Consider Christianity as an example. The experience of many is that faith brings a deep joy that surpasses day to day happiness and upset. However, Christianity does not always bring happiness. Christ claimed he was God's son and was crucified for it. Many who followed him since have been martyred for their beliefs, and countless more suffer daily persecution for being called “Christian.” Living out the Christian faith in itself is hard work. Therefore it matters whether this faith is based on truth.2

      The spiritual side of clinical care is important. We should be careful, however, to avoid misleading spiritual platitudes that bring happiness at the expense of truth.

      Footnotes

      • Competing interests MH is a Christian.

      References

      1. 1.
      2. 2.

      Spirituality is not everyone's cup of tea for treating addiction

      1. Ed Day, specialist registrar in addiction psychiatry (ejday{at}blueyonder.co.uk),
      2. Simon Wilkes, psychologist,
      3. Alex Copello, consultant psychologist
      1. Holme Tower, Marie Curie Centre, Penarth, South Glamorgan CF64 3YR
      2. Worcestershire Acute Hospitals NHS Trust, Worcester WR5 1DD
      3. Addictive Behaviours Centre, Birmingham B4 6SX

        EDITOR—Culliford's editorial about spirituality in medicine raises some important issues.1 In alcohol and drug treatment the spiritual dimension can play a part in recovery. The 12 step model developed by Alcoholics Anonymous has several important therapeutic elements, one of which is promoting the development of spirituality, and the large Project MATCH study of drinking outcomes found 12 step facilitation to be as effective as other forms of psychological treatment.2

        We recently conducted a questionnaire survey of 60 people attending Narcotics Anonymous groups in the West Midlands. We asked the attenders to rate their level of group attendance and participation, their belief in a higher power, and the amount of time that they devoted to any form of spiritual practice. The results showed that 90% of the participants had a belief in a power greater than themselves, and on average 50% allowed time for spiritual practices at least once daily. Linear regression analysis showed that spiritual practices, along with attendance and engagement with the self help groups, were significant predictors of abstinence in this group of substance misusers.

        The finding that participants allow themselves some time to engage in spiritual activities every few days is consistent with the work of Finney and Maloney, who found meditation to be an effective means of preventing relapse in this group.3 It also links to Geisler's work, which shows that spiritual practices combined with psychosocial treatment are effective aids to misusers in reducing their drug use,4 as well as to other work that indicates that prayer and meditation positively influences coping.5

        We believe, however, that the spiritual dimension is potentially a double edged sword for engagement in self-help groups. Although Alcoholics and Narcotics Anonymous have over two million members worldwide, few of the people whom we treat use this free and readily available form of long term help. Our clinical experience implies that the perceived “religious” or spiritual element of the process is a strong reason to stop attending self help groups of these organisations, particularly in the early stages.

        Footnotes

        • Competing interests None declared.

        References

        1. 1.
        2. 2.
        3. 3.
        4. 4.
        5. 5.
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