Abstract
Translating medical findings into meaningful public and professional messages is challenging in any clinical trial, and is even more challenging when studying something as intangible, and as politically and polemically charged, as the role of prayer in healing. While prayer is arguably the oldest and most ubiquitous of all healing therapeutics, we must recognize that the scientific literature on prayer is in its infancy. We have no mechanistic understanding whatsoever as to how prayer actually operates in the practice of medicine. The very fact that serious scientific research into prayer and healing is coming forward, and not from schools of voodoo, but from the Mayo Clinic, Duke University, Columbia University, and Harvard, is significant. 1 –4 Whether as scientists, the lay public, or the media, “we” are all destined to become patients in need of optimal medical care sooner or later, and so might reflect together on whether narrow and contentious debate about any single study examining whether prayer heals is nearly as important as the trend of leading academic researcher centers developing serious interest in whether intangible human capacities such as compassion, love, joy, the human spirit, or prayer can measurably augment the outcomes we see within the allopathic application of our most advanced medical technologies. 5
Clinical studies of such ubiquitous healing practices as prayer, with no plausible mechanistic explanation, can be meaningful, but cannot be represented as “pass/fail” tests by anyone, either clinicians or media. Well-designed studies may serve as efforts to structure information so that we might all learn something—specifically about the role, effects, or even possibly some of the mechanisms through which intangible adjuncts might improve outcomes in our high-tech world of health care. Most predictably, the role of scientific inquiry in such early stages of research will be useful to fashion better, clearer questions, or hypotheses; and for the advance of medical practice, clinical research applying clearer, more informed questions provides the real substrate from which more definitive, more impactful answers may arise.
As ongoing interest propels further studies from leading research centers, we might briefly reflect on just what it is that we want and need to know about prayer and healing. At this early stage, when we are still unclear how a “dose” of healing prayer might even be defined, clinical trials are best understood by their context, rather than simply by their specific findings or other provocative details.
Cultural Versus Professional Perspectives on Prayer and Healing
In the largest context, we must be aware of the very different needs of the cultural and the scientific communities regarding research on prayer and healing. From a cultural perspective, understanding the healing power of prayer is based largely on faith, supported by testimonial, sacred traditions and practices, and constitutes a belief system pragmatically defined within particular ethnic communities. Recitation of healing prayer may be encouraged by the congregation, does not need a doctor's prescription, and is neither justified by nor in need of statistically tested data to fulfill its objectives.
For medical science and professional practice guidelines, however, a more systematic definition of healing methods, as well as more formal reproducibility and safety/effectiveness data specific to particular patient populations is mandatory. 5 Data-driven practice is a hallmark of modern medicine, and fundamental to the integration of new therapies that advance the practice of medicine. Especially for intangible therapies such as spiritual interventions, professional practice integration has very different requirements than cultural use. Developing a better understanding of what skills and training belong in the core curricula of medical, nursing, and related professional schools, as well as revisiting the roles and responsibilities across medical staff in hospitals for application of therapies such as prayer are all fairly novel challenges for integration of this ancient healing practice. Even the basis for professional certification in prayer-related skills is dependent on the evolution of some common, systematic basis of nomenclature, technical practices, and demonstrated safety and utility.
Are Scientific Methods Relevant to Prayer and Healing?
In addition to distinguishing the needs of cultural versus clinical applications of healing prayer, another critical context to understand is how to best apply the scientific process per se—generally used to study more tangible entities—to the study of an intangible, widely practiced, but poorly understood healing intervention such as prayer. For tangible therapies, such as new drugs, the molecule is chemically characterized, then tested in a biochemical model and then in an animal before it is ever used in humans. Results from human trials of drugs generally are “pass/fail” tests, with a negative study implying that the drug does not work in the setting tested.
Clinical research into therapeutic prayer effects can be seen as exactly the opposite paradigm. Millions of human beings are already exposed daily to healing prayer with no plausible mechanistic concept of how it might work. In this setting, clinical trials may be most useful in providing clues as to how medical science might improve if, in addition to our finest technology, we paid more attention to other aspects of a human being's intangible healing capacities. This is the opposite of a “pass/fail” test—it is the use of systematic tools such as outcomes models and related clinical science to gain or impute knowledge and to refine hypotheses that become the basis of further, better, more informative research. In this setting, a negative primary endpoint may help clarify erroneous or flawed underlying assumptions, while a positive secondary endpoint may provide critical clues on just where or how our assumptions might be revised.
The ubiquity of ambient prayer highlights another key contextual element of prayer research—the recognition that no study design can absolutely test the healing power of prayer. No design has emerged for a “prayer proof” room, and no study has asked family to not pray for loved ones—the former would be unfeasible and the latter would be unethical. While critical to recognize that no study design can address whether prayer heals, it is equally important to understand that scientific design can more reliably examine potential incremental benefits of healing prayer (e.g., outcome effects related to prayer specifically added by protocol). Even to test incremental benefit, however, investigators must acknowledge that many patients in the “standard care” arms of such studies may have people praying for their well-being. The MANTRA I and II studies found that, in urgent settings, almost 50% of patients were aware of prayer on their behalf and in elective settings almost 90% were aware of such “off-protocol” prayer. 1,6
Endpoints in Healing Prayer Trials: Is Death a Negative Endpoint?
Another critical contextual point in prayer research is the selection of study endpoints. Whether or not a treatment effect is observed for any therapy may heavily depend on the endpoints measures selected. In cardiology, death is frequently taken as a negative clinical outcome. From a spiritual perspective, however, death may not necessarily be viewed as negative at all—a lesson most recently applied in palliative care settings, where healing may have more to do with peace of mind and comfort than with curing a disease or delaying death. In fact, in many cultures, prayers for the sick and dying contain elements that focus on facilitating the release of the spirit from the suffering of the body—a focus where spiritual “success” could be manifest as physiologic death.
Whether clinical endpoints are perceived as detrimental or beneficial may also change over time or with deeper insight. In the STEP study, the most significant finding was an increase in the irregular heart rhythm, atrial fibrillation, following heart surgery in patients who were assigned intercessory prayer by protocol and who were told of that assignment (unblinded). 2 Atrial fibrillation requires treatment, can prolong hospitalization, may cause stroke or transient heart failure, and therefore is characterized by the Society of Thoracic Surgery (STS) as an adverse postoperative event—one of the measures used in the STEP study to assess postoperative response to prayer therapy. Thus, on the one hand, we should be concerned about whether the study as designed or the prayer therapy itself was potentially unsafe for patients about to undergo bypass surgery. On the other hand, in the same way we need to be thoughtful about when or how we consider death to be a “negative endpoint,” the same can be said about atrial fibrillation. Atrial fibrillation is a transient event for many postoperative patients. Perhaps some day, from a more holistic, energetic perspective, we will come to appreciate some other aspect of this transient event on recovery and rehabilitation that actually strengthens the body, mind, or spirit. Indeed, it is conceivable that history will prove the STEP study to be the first to show a beneficial effect of prayer on postoperative healing, even though by primary study design endpoint definitions, it showed an adverse effect.
While cultivating awareness of assumptions intrinsic to the research use of classical adverse clinical outcomes, primary safety concerns cannot be overlooked. Many medical therapeutics that intuitively seemed safe have proven to be problematic when careful studies are performed, and prayer cannot be exempted a priori. Mystical teachings worldwide remind practitioners in many languages that she who looks too directly upon the face of God, may be destroyed. Vigilant attention to the safety of human subjects who participate in clinical trials—even trials that study something as “safe” as healing prayer—constitutes a mandatory and ongoing ethical and scientific consideration. 5
As more interest and solid science emerge in the arena of intangible human capacities, including spiritual interventions such as prayer, what we really want or need to know are key questions both for scientists and the lay public, as well as for the media who are so central as the bridge of communication between the two. In The Lancet editorial, “Measuring the Unmeasurable,” 7 which accompanied publication of the “negative” MANTRA II study, The Lancet senior editors wrote that intangible or “noetic” human capacities such as spiritual intervention and prayer “are proper subjects for science, even while transcending its known bounds.” Scientists, the public, and the media should all be inspired to think more deeply about what these studies mean for the future of medicine, rather than to simply sink to sensational arguments based on narrowly sliced, devilish details.