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Medicine, Religion, and Health
Where Science & Spirituality Meet
By Harold G. Koenig
Templeton Foundation PressCopyright © 2008 Harold G. Koenig
All rights reserved.
Terms of the Debate
Whenever I give a public talk on religion and health issues, I try to avoid one thorny topic in particular: defining the differences between the words religion and spirituality. This can easily alienate a significant proportion of the audience because each of us has our own definitions for these words, which we hold onto quite dearly. In this book, however, I have the luxury of spending some time exploring these terms in depth. Establishing definitions now for how I am using these terms will help the reader understand what the research means and will assist medical professionals in applying the findings to their clinical practices.
Without crystal-clear definitions, research on religion, spirituality, and health is not possible. For example, if a relationship is discovered between "spirituality" and longevity, what does that mean? The word longevity is widely understood as meaning years of life, and this can be calculated precisely by knowing birth and death dates. In contrast, there is no universal agreement on the more nebulous term spirituality. But if a relationship between spirituality and longevity is found, we need to know what this thing "spirituality" is in order to understand what exactly is related to a long life span.
We also need to know how spirituality differs from other psychosocial concepts, such as psychological well-being, altruism, forgiveness, humanism, social connectedness, and quality of life. Spirituality must be unique and different from everything else, a completely separate phenomenon, which can then be examined in its relationship to health. Our task in conducting research is to quantify how spiritual the person is (determine the extent or degree that the person is spiritual) and describe in what ways he or she is spiritual. This is absolutely necessary in order to determine how spirituality is related to health.
To focus on these distinctions, this chapter compares four concepts—religion, spirituality, humanism, and positive psychology —with particular attention paid to spirituality, since this is such a commonly used term today. The meaning of the term spirituality has broadened in recent years to include positive psychological concepts such as meaning and purpose, connectedness, peacefulness, personal well-being, and happiness. According to researchers Christian Smith and Melinda Denton, "The very idea and language of 'spirituality,' originally grounded in the self-disciplining faith practices of religious believers, including ascetics and monks, then becomes detached from its moorings in historical religious traditions and is redefined in terms of subjective self-fulfillment." This new version of spirituality has evolved to include not only aspects of life that have nothing to do with religion but often excludes religion entirely, as in the statement "I'm spiritual, not religious." This can make spirituality indistinguishable from concepts that are secular.
There are both positive and negative consequences to broadening of the term spiritual. In this book, which focuses on research, I will argue that we need to reinstate a sharper definition of spirituality that retains its historical grounding in religion. Nevertheless, I will admit that the broadening of the term has a valuable clinical application. As we shall see, then, spirituality can be profitably used in two different ways, more narrowly in research and more broadly for patient care. Before presenting a definition for spirituality, however, I will first define religion and then review attempts by others to define spirituality as something unique and different from religion.
Religion may be defined as a system of beliefs and practices observed by a community, supported by rituals that acknowledge, worship, communicate with, or approach the Sacred, the Divine, God (in Western cultures), or Ultimate Truth, Reality, or nirvana (in Eastern cultures). Religion usually relies on a set of scriptures or teachings that describe the meaning and purpose of the world, the individual's place in it, the responsibilities of individuals to one another, and the nature of life after death. Religion typically offers a moral code of conduct that is agreed upon by members of the community, who attempt to adhere to that code.
Religious activity may be public, social, and institutional ("organizational" religiosity) or can be private, personal, and individual ("nonorganizational" religiosity). Organizational religiosity involves attending religious services, meeting as a group at other times for prayer or scripture study, or involvement with others in church-related activity, such as evangelism, fund-raising, financial giving or church-related volunteering (I use the term church here for succinctness and ease of reading. What is intended is church, synagogue, mosque, or temple). Nonorganizational religiosity refers to religious activity that is done alone and in private, such as praying or communicating with God at home, meditating, reading religious scriptures, watching religious television or listening to religious radio, or performing private rituals such as lighting candles, wearing religious jewelry, and so forth.
Although religious practices (public and private) often reflect how deeply religious a person is, this is not always the case. To fill this gap, there is a dimension of religion that has to do with the importance or centrality of religion in life. This has been called subjective religiosity and is measured by researchers with self-ratings of religious importance or overall religiousness. There is also a motivational dimension of religion that is closely related to subjective religiosity but that asks why the person is religiously involved. What motivates the person to be religious? Is religion sought for its own value, i.e., as an end in itself ("intrinsic" religiosity), or is it being used as a means to some other end that is ultimately more important, such as social position or financial gain ("extrinsic" religiosity)? Although the organizational, nonorganizational, subjective, and motivational aspects of religion are considered by some to be the most salient, there are many other dimensions, including religious belief or orthodoxy, religious knowledge, religious coping, religious quest (or seeking), religious history, religious maturity, and religious well-being.
In addition to its traditional form, religion also has a nontraditional shape, since it can be used to describe a wide array of groups guided by common beliefs and rituals. These include astrology, divination, witchcraft, invoking of spirits, spiritism, and a variety of indigenous, folk, or animistic rituals and practices related to the supernatural. Under my definition, therefore, religion is a unique domain with multiple dimensions that can be measured, quantified, and examined in relation to health and medical outcomes. Most high-quality research on religion, spirituality, and health actually ends up measuring religion, even many studies that use the term spirituality in the title or when discussing results.
I propose that, for pragmatic reasons there should be two definitions of the term spirituality: one for conducting research and studying the relationship between spirituality and health and one for applying what has been discovered to the care of patients. But first, how is spirituality usually defined? It has become a popular and accommodating term, especially in secular academic circles, because its vagueness, broadness, and dependence on self-definition. This term can include everybody, even the nonreligious. Below are several definitions for the term by experts in the field. The first three are definitions developed by health professionals involved in the clinical care of patients, which helps to explain why they are so broad and inclusive:
: The definition [of spirituality] is based in every person's inherent search for ultimate meaning and purpose in life. That meaning can be found in religion but may often be broader than that, including a relationship with a god/divine figure or transcendence; relationships with others; as well as spirituality found in nature, art, and rational thought.
: The concept of spirituality is found in all cultures and societies. It is expressed in an individual's search for ultimate meaning through participation in religion and/or belief in God, family, naturalism, rationalism, humanism, and the arts. All of these factors can influence how patients and health care professionals perceive health and illness and how they interact with one another.
: Spirituality is a complex and multidimensional part of the human experience. It has cognitive, experiential, and behavior aspects. The cognitive or philosophic aspects include the search for meaning, purpose, and truth in life and the beliefs and values by which an individual lives. The experiential and emotional aspects involve feelings of hope, love, connection, inner peace, comfort and support. These are reflected in the quality of an individual's inner resources, the ability to give and receive spiritual love, and the types of relationships and connections that exist with self, the community, the environment and nature, and the transcendent (e.g., power greater than self, a value system, God, cosmic consciousness). The behavior aspects of spirituality involve the way a person externally manifests individual spiritual beliefs and inner spiritual state. Many people find spirituality through religion or through a personal relationship with the divine. However, others may find it through a connection to nature, through music and the arts, through a set of values and principles or through a quest for scientific truth.
Notice how these definitions of spirituality include meaning and purpose, inner peace and comfort, connection with others, support, feelings of wonder, awe, or love, and other healthy, positive terms. The definitions also make it very clear that spirituality does not have to involve religion—i.e., it can be completely secular. Here, spirituality is defined by however a person chooses to define it, but it always means something good—something that almost anyone would want to associate with. While such broad definitions work well in clinical practice, they cause havoc when trying to conduct research. The difficulty of measuring such a concept and examining its relationship to health, especially mental health, should be obvious. I will say more about this later.
Peter C. Hill and Ken Pargament, well-known researchers in this area, define spirituality in a more unique way to help distinguish it from other related concepts. They argue that in the United States and elsewhere there is
a polarization of religiousness and spirituality, with the former representing an institutional, formal, outward, doctrinal, authoritarian, inhibiting expression and the latter representing an individual, subjective, emotional, inward, unsystematic, freeing expression.... [S]pirituality can be understood as a search for the sacred, a process through which people seek to discover, hold on to, and, when necessary, transform whatever they hold sacred in their lives.... This search takes place in a larger religious context, one that may be traditional or non-traditional.... The sacred is what distinguishes religion and spirituality from other phenomena. It refers to those special objects or events set apart from the ordinary and thus deserving of veneration. The sacred includes concepts of God, the divine, Ultimate Reality, and the transcendent, as well as any aspect of life that takes on extraordinary character by virtue of its association with or representation of such concepts....
In another article, Pargament further explains:
I see spirituality as a search for the sacred. It is, I believe, the most central function of religion. It has to do with however people think, feel, act, or interrelate in their efforts to find, conserve, and if necessary, transform the sacred in their lives. Let me say a bit more about the sacred. In the Oxford English Dictionary, the sacred is defined as the holy, those things "set apart" from the ordinary, worthy of reverence. The sacred encompasses concepts of God, the divine, the transcendent, but it is not limited to notions of higher powers. It also includes objects, attributes, or qualities that become sanctified by virtue of their association with or representation of the holy.
David J. Hufford, an authority in the medical humanities who holds a Ph.D. in folklore and folk life from the University of Pennsylvania, makes the following observation:
The odd thing about the inconsistency, vagueness and worry by investigators over these terms [religion and spirituality] is that they do have consistent, concise meanings in ordinary speech, and they relate to one another in a perfectly ordinary way. We are accustomed to pairs of words such as learning and education or health and medicine, where the former word identifies a broad domain and the second word refers to an institutional aspect of that domain.... Not all learning happens in schools and not all health behavior takes place in clinics or hospitals. Spirituality and religion stand in the same relation. Spirituality refers to the domain of spirit(s): God or gods, souls, angels, kjinni, demons. In short, this is what was once called the supernatural (and still is by many English speakers). When spirituality refers to something else it is by metaphorical extension to other intangible and invisible things....
In attempting to generalize his observations, Hufford specifically comments on the applicability of what he is saying to Eastern traditions.
It is sometimes suggested that spirit(s) comprise a Western category and that some traditions, Buddhism being an often cited example, lack the concept. But as long as the concept is kept simple in definition this is not a valid criticism. The concept of reincarnation in Buddhism may not involve a concept analogous to the Western idea of a soul in some of its versions, but it nonetheless does involve something invisible and intangible that is a kind of essence of the person that reincarnates.... It is sometimes claimed that Buddhism is not a religion, sometimes defended on the basis that it is not theistic. Even apart from the fact that much of Buddhist beliefs and practice around the world DOES involve gods, clearly Buddhism is an institution organized around such ideas as reincarnation and Nirvana and it teaches practices that affect the intangible part of the human, the part that progresses or degenerates, that approaches enlightenment and Nirvana.
In the end, Hufford defines spirituality simply as "personal relationship to the transcendent" and religion as "the community, institutional aspects of spirituality."
For research purposes, my definition of spirituality comes closest to Hufford's. To facilitate measurement as a unique and distinct concept, I believe we should return the definition of spirituality to its origins in religion, whether traditional or nontraditional. In its historical usage, the term spirituality has its roots in the patristic era and later spiritual thought derived from monastic life, the mendicants, the late Middle Ages, Luther, Ignatius, Teresa, and John of the Cross. Because the word spirituality has historically been associated with religion or the supernatural and involves religious language, I argue that, to call something spiritual, it must have some connection to religion.
Bear in mind that my definition of religion above includes nontraditional religious expressions. These include astrology, divination, witchcraft, folk traditions, or other indigenous healing practices that involve invisible spirits and spiritual forces that are outside of the individual yet are often practiced with others as part of a community with a set of beliefs, rituals, and moral code. My definition of the word religion also includes personal and private kinds of beliefs and activities not tied to organized or institutional worship. Religion also includes searching for or seeking the Sacred or transcendent, as the religious quest dimension would measure. However, if there is no connection with either religion or the supernatural, then I would not call a belief, practice, or experience spiritual. I would call it humanistic. An apt definition of the latter would be the following:
Humanism is a broad category of active ethical philosophies that affirm the dignity and worth of all people, based on the ability to determine right and wrong by appeal to universal human qualities—particularly rationalism. Humanism is a component of a variety of more specific philosophical systems, and is also incorporated into some religious schools of thought. Humanism entails a commitment to the search for truth and morality through human means in support of human interests. In focusing on the capacity for self-determination, Humanism rejects transcendental justifications, such as a dependence on faith, the supernatural, or divinely revealed texts.
Excerpted from Medicine, Religion, and Health by Harold G. Koenig. Copyright © 2008 Harold G. Koenig. Excerpted by permission of Templeton Foundation Press.
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