Experiments on Distant Intercessory Prayer, God, Science, and the Lesson of
Massah

Author Information
<http://archinte.ama-assn.org/issues/v161n21/rfull/#aainfo>   John T.
Chibnall, PhD; Joseph M. Jeral, MD; Michael A. Cerullo, MD

ARCHIVES OF INTERNAL MEDICINE
November 26, 2001
Vol 161, No 21, pp 2517-2640

ICM00048
For if you should enter into the temple for no other purpose than asking,
you shall not receive. And if you should enter it to humble yourself, you
shall not be lifted . . . it is enough that you enter the temple invisible.
. . . God listens not to your words save when He Himself utters them through
your lips.Kahlil Gibran, The Prophet
EXPERIMENTAL studies on the health effects of distant intercession (prayer)
ignore important facets of construct validity, philosophy of science, and
theology while focusing on issues like randomization and double-blinding.
These tendencies reflect a desire on the part of researchers to remove
nature as a causal factor when intercession seems efficacious. We argue that
close attention to construct validity of cause-and-effect variables
invalidates distant intercessory prayer as a scientific construct. Further,
the application of statistical techniques to metaphysical causal phenomena
is critiqued. We conclude that research on the effects of religion and
spirituality on health should avoid attempting to validate God through
scientific methods.



INTRODUCTION



There exist only a handful of recent experimental studies designed to test
the efficacy of distant intercessory prayer for health problems. 1-7
<http://archinte.ama-assn.org/issues/v161n21/rfull/#r1>  Wishing to help
fill the gaps in this deficient literature, wea "representative" cross
section of the 3 major Western Judeo-Christian traditions (Catholicism,
Judaism, and Protestantism)attempted to design an experimental distant
prayer intervention study for major depression. This exercise led to
disenchantment with the endeavor rather than a study design. Beginning with
questions about research validity, we progressed into arguments about the
nature of reality and the philosophy of science. Ultimately, we became
convinced that the very idea of testing distant prayer scientifically was
fundamentally unsound. The remainder of this article discusses each of these
steps in some detail.



ISSUES OF CONSTRUCT VALIDITY



The feeling that all was not right with the intercessory prayer research
emerged early and centered around our attempts to address the construct
validity of our proposed study. In their seminal work on research validity,
Cook and Campbell 8 <http://archinte.ama-assn.org/issues/v161n21/rfull/#r8>
defined construct validity (with respect to causes) as the extent to which
the operations meant to represent the causal factor (ie, the treatment or
independent variable) actually reflect some theoretical construct of
interest. When operations fail to incorporate critical dimensions of the
theoretical construct, "construct underrepresentation" results (ie, low
construct validity).
So, we began by attempting to avoid what Cook and Campbell called
"inadequate preoperational explication of constructs." 8
<http://archinte.ama-assn.org/issues/v161n21/rfull/#r8>  The way to do this
is to choose operations depending on the result of a rigorous theoretical
and conceptual analysis of the essential features of the causal construct.
But what were the critical dimensions of the construct prayer? Prayer, by
definition, is "an address or petition to God or a god in word or thought."
9 <http://archinte.ama-assn.org/issues/v161n21/rfull/#r9>  But what else
matters?
The list we generated began as follows: Is the amount of prayer important?
Is the type of prayer important? The form? The duration? The frequency? The
level of fervency? The entity to whom it is directed? The number of prayers
per unit of time? Does the number of intercessors matter? Does a team vs
individual intercession method matter? Does the faith tradition of the
intercessor and/or intercessee matter? Does the power of the intercessor
matter? Do the beliefs and experiences of the intercessor and/or intercessee
matter? Does the worthiness of the intercessor and/or intercessee matter?
This list, unfortunately, generated questions of its own: If type or form is
important, just how many types or forms are there? On what basis would you
distinguish them? If "fervency" is important, how would you ever measure it
to be able to manipulate it? The same is true if the power or worthiness of
the intercessor is important: how would you ever measure them? An
examination of the distant prayer studies did not help and only reinforced
our growing suspicions. Prayer was not explicated well in these studies.
Typical studies used constellations of intercessors from various faith
traditions praying in decidedly individual ways. 2-7
<http://archinte.ama-assn.org/issues/v161n21/rfull/#r2>  For example, the
intercessors (Protestants, Catholics, and Jews) in the study by Walker et al
6 <http://archinte.ama-assn.org/issues/v161n21/rfull/#r6>  were asked to
make "general positive intentions as opposed to specific requests" but "were
free to pray in whatever way they chose." In an attempt at standardization,
the intercessors in the study by O'Laoire 4
<http://archinte.ama-assn.org/issues/v161n21/rfull/#r4>  were instructed in
a 1-hour training session about "theories of intercessory prayer"; the
importance of relaxation, positivity, focus, imagery, and "confident but
effortless intentionality" when praying; and the difference between directed
and nondirected prayer (directed prayer ["very specific as to outcome"] vs
nondirected prayer [seeks "alignment with divine will"]). However, the
intercessors were not described with respect to who they prayed to; what
tradition guided their own prayer; what they actually did, said, and felt on
the days that they prayed; or how long they prayed. The intercessors in the
study by Harris et al 3
<http://archinte.ama-assn.org/issues/v161n21/rfull/#r3>  were required to
believe in a personal God who is "responsive to prayers for healing made on
behalf of the sick." 3
<http://archinte.ama-assn.org/issues/v161n21/rfull/#r3>  They then prayed
daily for a "'speedy recovery with no complications' and anything else that
seemed appropriate to them." The healers in the study by Sicher et al 5
<http://archinte.ama-assn.org/issues/v161n21/rfull/#r5>  all had "previous
healing experience at a distance" and included Christians, Jews, Buddhists,
Native Americans, shamans, and graduates of "schools of bioenergetic and
meditative healing." They were instructed to "direct an intention of health
and healing to the subject." Matthews et al 7
<http://archinte.ama-assn.org/issues/v161n21/rfull/#r7>  reported that 2
Christian prayer ministers (from Christian Healing Ministries, Jacksonville,
Fla) offered"for the health of the patient""at least 10 minutes of daily
prayer" individually and shared prayer (ie, both ministers prayed together
in person or by telephone) at least weekly. 7
<http://archinte.ama-assn.org/issues/v161n21/rfull/#r7>  The intercessors in
the study by Byrd 2 <http://archinte.ama-assn.org/issues/v161n21/rfull/#r2>
were "'born again' Christians (according to the Gospel of John 3:3),"
including Protestants and Catholics who prayed "daily for a rapid recovery
and for prevention of complications and death, in addition to other areas of
prayer they believed to be beneficial to the patient." 2
<http://archinte.ama-assn.org/issues/v161n21/rfull/#r2>  While all studies
seemed to keep track of the volume of prayer offered over the course of the
intervention, they only manipulated (crudely) the occurrence or
nonoccurrence of distant prayer. Why?
This state of affairs did not seem to be accidental. Perhaps prayer was
inadequately explicated because it could not be adequately explicated. We
found ourselves wondering what theoretical conceptualization of prayer could
ever answer all of these construct validity questions. More important, the
following question arose: If prayer is a metaphysical concept linked to a
supernatural being or force, why would its efficacy vary according to
parameters such as frequency, duration, type, or form? The very concept of
prayer exists only in the context of human intercourse with the
transcendent, not in nature. The epistemology that governs prayer (and all
matters of faith) is separate from that which governs nature. Why, then,
attempt to explicate it as if it were a controllable, natural phenomenon?
Consider an analogy. A clinical trial is planned to study the effect of
antibiotic agents on a new strain of respiratory bacteria. The investigators
go to great lengths to ensure random assignment, placebo control, and
double-blinding (as did our distant intercessory prayer researchers). But
this is not all they go to great lengths to ensure. They control the type of
antibiotic, the dose of the antibiotic, the dosing schedule of the
antibiotic, the coadministration of other medications that have antibiotic
effects or interfere with antibiotic effects, and the duration the
antibiotic is taken, to name a few of the most obvious parameters. Why?
Because all of these factors are critical to the construct validity of the
cause; that is, they are part of the definition of "antibiotic." If the
researchers ignored these characteristics of the causal agent or let them
vary capriciously, the results of the study, no matter what the outcome,
would be greatly reduced in interpretability. But this is the very state of
affairs inherent in distant prayer research. The explanation for this state
is that there is no reasonable theoretical construct to which to link prayer
because of, we would argue, its very nature. No model guides our
understanding of intercessory prayer as a treatment in the way we know that
drug pharmacokinetics, type, dose, schedule, interactions, and treatment
length are critical to an antibiotic as a treatment. In fact, we believe no
scientific model can guide it.



A CONSTRUCT RESISTANT TO EXPLICATION



The problem becomes more fundamental than a simple lack of construct
validity. It is deeper than the question, "What are the essential features
of prayer?" The problem is in the construct itself. The more important query
is the follow-up question, "How can we know?" Even if you could identify
what you considered to be an essential feature of prayer, on what scientific
basis, with respect to what theoretical model, could you support your
position? For example, we propose that multiple prayers are more efficacious
than a single prayer. Our colleague asks the obvious question: Why should it
matter? What logic, reasoning, model, or theory could answer our colleague's
question? Unless we answer theologically, we cannot answer at all. Here is
another example: we propose that a prayer offered by 2 people is more
efficacious than the same prayer offered by 1 person. Why should it matter?
Again, there is no scientific answer. The fact is that there is no
scientific or theoretical way to answer these questions. They are about
personal relationships to God and are answered only by moral, theological,
philosophical, or spiritual methods that go beyond mechanistic causality. If
we cannot answer the questions scientifically, then the construct cannot be
studied through empirical research.
Yet, one might argue that if an empirical effect is found, it proves
something. On the contrary, we would argue that an empirical effect, which
(as the later section "Statistical and Measurement Issues" will show) is not
hard to find when dealing with human beings, means nothing to science
outside some link back to construct validity and nature. Hempel, 10
<http://archinte.ama-assn.org/issues/v161n21/rfull/#r10>  in his Philosophy
of Natural Science, has outlined basic criteria for scientific explanations.
He describes explanations of phenomena that provide psychologically or
spiritually valid answers (including God's will, power, or plan) as
inadequate for the purposes of science. Their inadequacy derives from their
failure to meet 2 essential scientific criteria: explanatory relevance and
testability.
Explanatory relevance refers to the requirement that an explanation for a
phenomenon must constitute grounds for expecting a given result under a
given set of conditions. When we offer that a rainbow will appear any time
light from behind an observer is refracted through water droplets in front
of the observer, the explanation has relevance to the phenomenon being
observed. That is, even without ever having seen a rainbow, the explanation
allows us to expect that under the conditions specified, one will appear.
(This criterion is similar to that of "prediction" as proposed by Lambert
and Brittan, 11 <http://archinte.ama-assn.org/issues/v161n21/rfull/#r11>
who state that for an explanation to be adequate in science, it must
indicate "why, given certain antecedent conditions, the event to be
explained could have been expected to occur.") Alternatively, if we offer
that rainbows are the bridge that souls cross to the afterlife, our
explanationnow and foreverhas no link to the observed phenomenon and allows
us no conditions under which to expect or predict the rainbow's occurrence
(which, of course, only matters with respect to science and not with respect
to spirituality, literature, culture, personal meaning, etc).
The second requirement is testability, or that a given explanation must be
empirically testable, in principle if not in reality. That is, a scientific
hypothesis must have certain "test implications," such that empirical
findings can either support it or contradict it. The fact that you can
create a research design for a given hypothesis does not ipso facto make the
hypothesis scientific. Hempel 10
<http://archinte.ama-assn.org/issues/v161n21/rfull/#r10>  offers the example
of entelechies or "vital forces" as explanations for the "organic
directiveness" that occurs in embryonic development. Experiments that
demonstrate repair of embryonic damage can and have been done. Yet a
hypothesis that this process is a function of entelechies would be neither
supported nor contradicted by the experimental results because the
entelechal explanation cannot make differential predictions regarding when
these forces will manifest and in what manner they do their directing. The
vital force is just "there." Hempel calls such hypotheses
"pseudo-hypotheses" (with respect to science, but not with respect to their
intuitive, spiritual, or psychological validity). Distant intercessory
prayer is no more testable than entelechies in this sense: God is there when
effects are found or not there when they are not. To derive specific
implications of such a hypothesis is not possible. It is akin to qualifying
an explanation of the origin of species through evolution with the proviso
that, while evolution may work within the principles of biology and
chemistry, it is really God who directs it. The proviso, while potentially
spiritually meaningful, is scientifically irrelevant (ie, it is without
explanatory relevance and testability). As Hempel 10
<http://archinte.ama-assn.org/issues/v161n21/rfull/#r10>  notes, it is not
permissible to propose a hypothesis and call it scientific, despite its lack
of test implications or suggestion by auxiliary hypotheses, solely for the
purpose of adding legitimacy to a deeply held conception.
The scientific explication of the construct prayer also contradicts many
spiritual and theological conceptions of prayer. It contradicts many
individuals' habits and beliefs regarding prayer and faith. For example,
*         What have we found if we find a significant difference in a
distant intercessory prayer study attributable to the number of intercessors
or frequency of prayer? Have we found a way to use science to manipulate
God, the omniscient, omnipotent creator of the universe? Or have we found
that God's "brain," like those that evolved in humans, appreciates an
additive, linear effect (eg, two 10-minute prayers by 1 intercessor equals
one 5-minute prayer by 4 intercessors)?
*         What have we found if we discover a significant difference between
Christian and Jewish intercessors? Validation of Christ? (No, as it turns
out. The futility of empirically validating the mystical has been clear to
many, including the deeply religious. At the turn of the last century,
William James, 12 <http://archinte.ama-assn.org/issues/v161n21/rfull/#r12>
philosopher and psychologist, asserted that "we cannot distinguish natural
from supernatural effects; nor among the latter know which are favors of
God, and which are counterfeit operations of the demon.") What are the
theological and social implications of a study pitting Jewish intercessors
against Moslem intercessors? (Would anyone dare such a study? Would the
National Institutes of Health fund it? Would any institutional review board
approve it?)
*         When Catholics each Sunday at Mass offer a communal special
intention to God to "heal all who are sick and suffering," is the
probability of efficacy higher or lower than a single Catholic praying for a
single individual (who would also be included in "all who are sick and
suffering")? How about a group of Catholics praying for a single individual?
These questions are not even askable, let alone answerable. In one author's
experience (J.C.), the priest himself has been known to follow this petition
with the proviso: "We have asked for what we think we need; give us what you
know we need."
*         In the major religious traditions, prayer that tests for a
response from God in the way the intercessor requires would not be
considered prayer at all because it requires no faith, leaves God no
options, and is presumptuous regarding God's wisdom and plan. Where is faith
if science can validate the power of prayer? Where is faith if the results
of research can influence whether, why, and how the devout (or nondevout)
will pray or if more and more precise explication of the construct prayer
can eventually produce a scientific law, thereby putting more and more
constraint on God? If distant prayer studies can make the results of prayer
consistent, predictable, and replicable, then faith has become science.
So, we are left with a causal construct that violates the scientific
requirements of explanatory relevance and testability, a construct for which
we are unable to discern essential features and their implications without
violating basic assumptions of faith. The only possible essential feature of
prayer is, perhaps, whether it occurs or not, and maybe whether it occurs
sincerely or not (but, again, how could you ever tell?). There is no
possible way, of course, to control its occurrence (remember all those
Catholics praying for all the sick every week), and if its sincere
occurrence is its only essential (but uncontrollable) feature, then all
other features are arbitrary and therefore not manipulatable. Prayer resists
scientific explication and, unfortunately, nature has nothing to say about
the ways of God.



A CONSTRUCT OUTSIDE THE BOUNDS OF SCIENCE



God is the purported causal mechanism in these studies, or God's equivalent.
Why else would the intercessors need to be blinded? Keeping the patients and
their physicians blind to the conditions is a reasonable approach; this
constitutes "double-blind" in the classic sense. Yet, all of the prayer
studies reviewed by Astin et al 1
<http://archinte.ama-assn.org/issues/v161n21/rfull/#r1>  went to great
lengths to ensure that the intercessors had no contact with their targets or
even knew who they were (some studies have provided pictures and/or first
names or initials of the targets, while others have not, but no study
identified the prayer targets). But why should that matter? If the
intercessor is blind to the target and prayer is the treatment, what is the
mechanism by which the effect occurs if it is not God, or at least some
metaphysical mediator or mediating process that functions omnisciently (eg,
we are told that the "healers" in the study by Sicher et al 5
<http://archinte.ama-assn.org/issues/v161n21/rfull/#r5>  were not
specifically directed to pray to God, but were told to "direct an
intention"; however, many of them were religious healers)? We maintain that
studies of distant prayer have had this feature not to test the effect of
prayer on human illness, but to test for God's intervention in response to
human intercession.
Intercessor-blind studies of prayer are analogous to therapist-blind studies
of psychotherapy or practitioner-blind studies of therapeutic touch. They do
not make sense. The mechanism of action cannot be differentiated from the
sentient human being who delivers it. In reference back to the antibiotic
treatment analogy, a blind intercessor is akin to an antibiotic stripped of
the property that enables it to inhibit cell wall production in a bacterium:
the intercessor knowing for whom he or she is praying is as much a part of
the "treatment" as the antibiotic's "knowledge" of how to inhibit cell wall
production, and only in bacteria cells. If we "blinded" the antibiotic, by
what process, if not miraculous, would it destroy bacteria? A prayer study
with blinded intercessors makes sense only if some omniscient mediating
phenomenon or process knows how and where to apply the mechanism of action
(and chooses to do so). If intercessors are blind, the researcher finding
significant differences has only 1 recourse to an explanation: God. (In the
study by Byrd, 2 <http://archinte.ama-assn.org/issues/v161n21/rfull/#r2>  no
attempt was made to hide this fact.) All possible natural phenomena
(bioenergy transference, magnetic wave affects, etc, all of which are worthy
of investigation) have been ruled out.
Moreover, why is it vital to these prayer studies that patients not know
that they are being prayed for? Why not study the placebo response directly?
For example, Do subjects who know that someone is praying for them do better
than subjects who do not know? Such a study would help to explicate the
nature of the mind-body interface, and would contribute to a fascinating and
powerful literature on expectancy effects in medicine. 13
<http://archinte.ama-assn.org/issues/v161n21/rfull/#r13> , 14
<http://archinte.ama-assn.org/issues/v161n21/rfull/#r14>  Such research
would neither deny nor support miracles, the hand of God, or the
providential effect of prayer; it would simply say nothing about them.
Recently, Matthews and MacNutt (both well-published and unabashed advocates
for the healing power of prayer), along with colleague Marlowe, 7
<http://archinte.ama-assn.org/issues/v161n21/rfull/#r7>  found interesting
(and, in some cases, substantial) effects of in-person prayer teams on
symptoms of rheumatoid arthritis outpatients (while, incidentally, finding
no effect for distant intercessory prayer). They acknowledged the potential
role of placebo in their findings and speculated on the mechanisms of action
involved in the changes they documented (including immunological effects).
They also challenged future researchers to differentiate the effect of
in-person prayer from other forms of sympathetic clinical attention, both
spiritual and nonspiritual. None of these notions requires a supernatural
construct. Consider, by contrast, the hypothesis of Sicher et al 5
<http://archinte.ama-assn.org/issues/v161n21/rfull/#r5>  that distant
healing might involve "previously undescribed energy transfer" or
"mind-to-mind communication." Why then, if they are willing to consider a
natural phenomenon as the causal agent, were their intercessors blind? If
the intercessors were transferring energy or somehow healing disease by
communicating telepathically, would it not be imperative that there be a
known destination for this energy or a known mind with which to communicate?
(These questions can be asked as well of much of the secular, nonprayer
distant healing research. 1
<http://archinte.ama-assn.org/issues/v161n21/rfull/#r1> , 15
<http://archinte.ama-assn.org/issues/v161n21/rfull/#r15> ) Why not have the
intercessors surreptitiously sit outside the examination room and direct
their intention right at the patient? Why not look for disturbances in the
electromagnetic field around patients when an intercession is occurring? Why
not test in-person healing with a random assignment of healers directing
intentions vs nonhealers (pretending to be healers) reciting nonsense
syllables in their heads? Clearly, there are alternatives to testing for
God's intervention, alternatives that are fascinating, useful, and, above
all, consistent with a scientific approach without being theologically
untenable.
The fact that it is God (or God's equivalent) that is being tested is the
fundamental distinction between explaining the results of distant prayer
studies and explaining the mysterious findings of other research (in which
the history of medical research abounds). Darwin did not have access to
Mendelian genetics when he developed the theory of evolution by natural
selection. He did not know how offspring acquired subtle differences from
their parents in ways that favored survival. Yet, this did not invalidate
his theory. The difference is that what Darwin observed did not presuppose a
supernatural construct as an explanation; it allowed nature and
experimentation at some point in time to furnish an explanation. If we find
contradictions in nature it is not because contradictions exist in nature,
it is because we do not know nature well enough. As Verschuuren 16
<http://archinte.ama-assn.org/issues/v161n21/rfull/#r16>  notes, Darwin's
theory had an "in-built capacity to adapt to new developments, to grow into
new fields, and to provide a delimited and reduced mechanism of speciation
that allowed many small-scale experiments. . . ." (italics ours).
Unfortunately, in practice the distant prayer studies remove nature from the
equation, substituting God in its place. But as we shall see, God is neither
confined by the natural world nor amenable to being experimented on, low P
values notwithstanding.



STATISTICAL AND MEASUREMENT ISSUES



If God Is Infinite, So Are alphaand beta

The role of God as the mechanism by which distant prayer works separates
prayer research from science in other ways as well, most notably in the way
statistical and measurement issues have been applied. For example, Why are
statistical tests necessary to detect differences if God is in the works?
Does it make sense that God would operate probabilistically? Why would there
be any overlap in the score distributions for those getting the treatment vs
those not? And, judging from the effect sizes in the distant intercessory
prayer research, there is plenty of overlap. On an individual human being
basis, what are we to make of the 40% of the control group who did better
than the mean of the treatment group (when, on average, the control group
did worse) and the 40% of the treatment group who did worse than the mean of
the control group (when, on average, the treatment group did better)? If the
mechanism is miraculous and metaphysical, the need for probability
statements and the overlap of distributions is difficult to explain. A
related issue is the very idea of subjecting God to probabilities as we set
them up. With respect to God's intercession in the world, it is clear from
many of the major religious traditions that God is not bound by natural laws
or probabilities. Rabbi Luzzatto 17
<http://archinte.ama-assn.org/issues/v161n21/rfull/#r17>  makes this clear
in his explication of God's workings in the world, including miracles, from
a Jewish perspective:
The spiritual consists of all entities which are not physical and which
cannot be detected by physical means [I:5:1]. . . . Every physical entity
and process is under the charge of some type of angel. These angels have the
responsibility of maintaining each of them, as well as bringing about
changes within them according to G-d's decree [I:5:2]. . . . When he wills,
G-d can change the order of creation at any time. He can bring about various
miracles and wonders, as He desires and deems beneficial for creation,
according to the time and circumstances [II:5:6]. . . . The Highest Wisdom
decreed . . . that these Forces [Kochos, a type of transcendental being]
should be able to act upon the physical world in another manner . . . that
conforms to their own innate laws, rather than the physical laws of nature.
It is through this mode of action that the normal laws of nature can be
suspended and altered on the physical plane [III:2:2]. [Italics ours.]
Attempts to impose statistical order on God become more absurd when we
consider the proposition on which null hypothesis significance testing is
actually based: "assuming the null hypothesis (of no effect, no difference,
no relationship, parameter µ = X, etc) to be true, how probable are the
results obtained?" 18
<http://archinte.ama-assn.org/issues/v161n21/rfull/#r18>  What question are
we asking with distant prayer research? "Assuming that God cannot heal at
the bequest of human intercessors, what is the probability of getting these
results?" (Keep in mind that a low probability does not then tell us that
ipso facto the null hypothesis is false. Significance testing assumes the
null hypothesis to be true; it cannot, therefore, yield a direct measure of
the falsity of the null. 18-20
<http://archinte.ama-assn.org/issues/v161n21/rfull/#r18>  Like many other
researchers, distant prayer researchers make the mistake of believing that a
low probability level allows them to "linguistically transform" their P
value into a meaningful finding for a given study. 20
<http://archinte.ama-assn.org/issues/v161n21/rfull/#r20>  In actuality,
statistics are a tool for evaluating error probabilities over the long run;
they are not an "index of truth." 21
<http://archinte.ama-assn.org/issues/v161n21/rfull/#r21> ) It is, perhaps,
absurd to even have a null hypothesis (that God has no effect), if there is
no way for it to be true (of course God can heal, when so inclined).
Statistical hypothesis testing also fixes probabilities for mistakes, the
classic type I error (ie, alpha, or the probability of rejecting a true null
hypothesis) and type II error (ie, beta, or the probability of failing to
reject a false null hypothesis). But can God be held to these parameters?
Must acts of God conform to a normal distribution as so many natural
phenomena do (or are assumed to do)? It makes no sense to conduct a power
analysis and set alphato a certain level if the laws of probability can be
rescinded at any time. If God is the mechanism, the flipped coin does not
have to, over time, yield half heads and half tails. If God is the
mechanism, the distribution of means from successive random samples drawn
from a population can take on any shape imaginable, at any time, at any
moment.
Consider an analogy. Suppose that nature consists of a large glass jar
filled with 50% blue marbles and 50% red marbles. As scientists, we want to
find out what proportion of marbles is red. We do not, of course, have
direct access to all the marbles. In fact, the only way to get marbles from
the jar is by using a marble interferometer. We test the hypothesis that the
proportion of marbles favors red (ie, that the proportion of marbles is not
50:50). We set up a mathematical model assuming that the proportion of red
marbles to blue marbles is equal, then calculate theoretical comparison
distributions based on an infinite number of random samples of various
sizes. This concludes the theoretical work (deductive reasoning), and we are
ready for the empirical work (inductive reasoning). We use the marble
interferometer to obtain a sample of marbles. We compare the proportion of
red marbles in our sample with what would be expected if the proportion of
red marbles was 50%. This is the simplest form of hypothesis testing. Where
are the flaws in the prayer studies relative to this analogy? The primary
problem relates to what happens when we obtain our sample. The prayer
studies have no equivalent to the marble interferometer. The process is more
analogous to an omniscient being (God) choosing specific marbles and handing
them to the experimenter. The actual sample is not chosen in the way that
the theoretically infinite random samples are chosen (with an
interferometer-like process) to generate a statistical comparison
distribution (in the case of both parametric and nonparametric statistics).
But it is with these comparison distributions that our actual samples are
compared in hypothesis testing. Statistical comparison distributions come
from a mechanistic model of the universe, while the actual sample in a
prayer study comes from a teleological model of the universe. Conventional
statistics just do not work in this model. (But can we test whether the
world is teleological by determining whether our data conform to mechanistic
models? No, because there are an infinite number of alternative naturalistic
hypotheses to explain any discrepancy. Science presumes a mechanistic
world.) With respect to statistical conclusion validity, 8
<http://archinte.ama-assn.org/issues/v161n21/rfull/#r8>  the distant prayer
studies were invalid before any data were even collected.
When the dutiful distant prayer researcher says that "there is an 80%
probability of a P value of less than .05 for differences of at least X," do
the powers of God suddenly become constrained? We think not. If God is
infinite, so are alphaand beta.
Measurement and the "Crud Factor"

A related issue involves the nature of the outcome variables for distant
prayer research. A review of these studies shows that the outcome variables
are generally abundant, sometimes "soft," and never theoretically and
conceptually grounded or differentiated. Cohen, 22
<http://archinte.ama-assn.org/issues/v161n21/rfull/#r22>  the godfather of
such primary statistical concepts as power analysis, has discussed in detail
Meehl's concept of the "crud factor." 18
<http://archinte.ama-assn.org/issues/v161n21/rfull/#r18> , 23
<http://archinte.ama-assn.org/issues/v161n21/rfull/#r23>  Basically, thanks
to the crud factor, on any given day everything can be related to everything
else in the context of soft theory, abundant opportunities (the infamous
"fishing" technique 8
<http://archinte.ama-assn.org/issues/v161n21/rfull/#r8> ), and/or soft
outcomes. Consider the study by O'Laoire 4
<http://archinte.ama-assn.org/issues/v161n21/rfull/#r4> : 11 outcomes,
including state and trait anxiety, self-esteem, mood, depression, and
self-perceived changes in creative expression and physical, emotional,
intellectual, spiritual, and relational health. All measures were
self-reported and the latter 6 were "home grown." (Regardless, O'Laoire
failed to detect an effect for distant intercessory prayer on psychological
health.) Consider the study by Harris et al 3
<http://archinte.ama-assn.org/issues/v161n21/rfull/#r3> : there were no less
than 35 parameters (for which the investigators made some adjustment in the
analysis), ranging from need for an electrophysiology study to death. As it
turned out, no single component achieved statistical significance as a
function of blinded distant intercessory prayer, but an unvalidated
"weighted and summed scoring system" did (but that only weakly). And in the
study by Sicher et al 5
<http://archinte.ama-assn.org/issues/v161n21/rfull/#r5>  11 outcome
variables with large standard errors (SEs) yielded a hodgepodge of
inconsistent, marginal results. 5
<http://archinte.ama-assn.org/issues/v161n21/rfull/#r5>  Although a
multivariate approach was used in an attempt to account for correlation
among outcomes, the recommended correction to the obtained univariate
probability values was not made. 24
<http://archinte.ama-assn.org/issues/v161n21/rfull/#r24>  In addition,
changes in statistical tests to account for severe distributional anomalies
of certain variables increased some P values beyond conventionally accepted
levels. Of the 11 outcomes, 4 changed significantly at an unadjusted
univariate level. Of these, 1 was a self-reported indicator of distressed
mood that, when adjusted for baseline differences, indicated more
improvement in the control group. The only truly objective variables, CD4+
levels and death, had the highest P values (.55 and >.99, respectively).
Finally, what of the oft-cited study by Byrd? 2
<http://archinte.ama-assn.org/issues/v161n21/rfull/#r2>  More than 2 dozen
uncorrected univariate comparisons of variables with very low frequencies or
large SEs (among which 6 statistically significant effects emerged) were
made, followed by a multivariate procedure that maximizes chance findings
(stepwise regression). 24
<http://archinte.ama-assn.org/issues/v161n21/rfull/#r24>  An unvalidated
"hospital course" grade ("good, intermediate, or bad") of unknown
reliability was also significantly different at a univariate level, but it
overlapped considerably with the 29 individual outcome parameters,
particularly the bad grade, which encompassed 4 of the 6 individually
significant factors. We propose that a crud factor–like mechanism is more
than sufficient to explain these and other positive distant prayer results,
as have others. 25-27
<http://archinte.ama-assn.org/issues/v161n21/rfull/#r25>
But even if it were not, what are we to make of prayer studies where only a
small fraction of the outcome measures change significantly? The related
conceptual and theoretical issues are at least as compelling as the
statistical ones. In no intercessory prayer study has there ever been an a
priori specification of outcome criteria. Which outcome variables do the
researchers expect to change, by how much, and, most important, why? This
gets back to the previous discussion of construct validity: the outcomes of
prayer resist explication as well (construct validity of the effect). The
result is a hodgepodge of variables, some of which change and some of which
do not. But there is never an explanation as to why some did and some did
not; no mechanism is ever proposed to address the differences. Even the
tentative explanation of Sicher et al 5
<http://archinte.ama-assn.org/issues/v161n21/rfull/#r5>  that distant
healing might be a function of "some previously undescribed energy transfer"
cannot explain how the energy knows where to go and why it affects
outpatient visits and not CD4+ levels. 5
<http://archinte.ama-assn.org/issues/v161n21/rfull/#r5>  Consider again the
study by Byrd. 2 <http://archinte.ama-assn.org/issues/v161n21/rfull/#r2>
The "Judeo-Christian God" apparently saw fit to require only 3 of the 192
intercessory prayer patients (1.6%) to need antibiotics, while permitting 17
(8.5%) of the 201 controls to experience this fate. Yet this same
"beneficial therapeutic" God did not significantly alter the number of
patients requiring, to name but a few, antiarrhythmic agents, pressure
monitoring, readmission to the cardiac care unit, vasodilators, pacemakers,
major surgery, and antianginal agents. Further, mortality rates were not
different as a function of prayer; neither were rates of sepsis, unstable
angina, or gastrointestinal bleeding; neither were cardiac care unit days,
total hospital days, or number of discharge medications. Why did God pick
antibiotics? Could this result have been predicted before the study? Could
differential predictions have been made regarding the mass of outcome
variables? The answer to each of the latter 2 questions is "No."
The choice of outcome variables is a telling and unfavorable commentary on
distant prayer research. Why are not more convincing approaches to outcome
constructs used in this line of research? Consider a distant intercessory
prayer study for blind persons, directed at the restoration of sight, with
secondary measures of change in subjective parameters such as well-being,
mood, or quality of life. A differential prediction could be made, and a
single objective outcome criterion exists. The same study could be done with
paraplegics with severed spinal cords, amputees, or the dead. If the
mechanism of action is Godly and miraculous, there is no logical reason to
shun these studies other than the most important reason: that they
trivialize and distort the nature of prayer, God, and our relationship to
the transcendent by bringing them into a sphere in which they do not belong.



ALTERNATIVES TO TESTING PRAYER



As our concerns with distant prayer research proliferated, we began to
consider the extent to which this line of research detracts from other more
productive activities regarding religion and medicine. Recently, numerous
commentators and researchers have presented pertinent information on a
variety of topics in this area, including physician attention to patient
religious needs, spiritual history taking in the clinic, sensitization of
medical students and residents to the importance of religion or spirituality
to patients facing health crises or death, epidemiological findings on the
health benefits of religion, the centrality of religion to the elderly
patient, and the universal role of religion in interpreting crises of
meaning (eg, premature death or disability) in the lives of human beings.
28-37 <http://archinte.ama-assn.org/issues/v161n21/rfull/#r28>
Much of this work has been done in the spirit of patient-centered medicine,
28 <http://archinte.ama-assn.org/issues/v161n21/rfull/#r28>  within a model
that acknowledges a portion of the physician's role concerned with
supporting, healing, caring, and palliating. This work has, for the most
part, been decidedly nondenominational, seeing the very diversity of patient
faiths as one driving force in the recognition of patient religion.
Moreover, researchers like Levin 33
<http://archinte.ama-assn.org/issues/v161n21/rfull/#r33>  have proposed
hypotheses for the relationship of religion to health that are grounded in
nature, including the role of religion in promoting good health behaviors
(eg, substance use and abuse, diet, and sex), the psychoneuroimmunological
effects of ritual and worship, the social support and relationships
engendered by religious affiliation, and the psychological effects of
religion as mediated by feelings of hope, forgiveness, love, optimism, and
joy. 33 <http://archinte.ama-assn.org/issues/v161n21/rfull/#r33>
Distant intercessory prayer studies project a distorted image (especially
when filtered through the media) of how science is accomplished and, perhaps
more important, what "truth" means in the context of belief, spirituality,
and religion. 38 <http://archinte.ama-assn.org/issues/v161n21/rfull/#r38>
The effect is to distract us from the more real and more human interaction
of religion and medicine: the acknowledgment that religion and spirituality
are often vitally important to our fellow human beings in their experience
of illness, disability, suffering, dying, and death. Considering ways of
bringing medicine closer to a recognition of that importance would be more
beneficial than applying the scientific method to prayer. 39
<http://archinte.ama-assn.org/issues/v161n21/rfull/#r39> , 40
<http://archinte.ama-assn.org/issues/v161n21/rfull/#r40>
The continued desire of some to do the latter misses the point anyway. As
Verschuuren 16 <http://archinte.ama-assn.org/issues/v161n21/rfull/#r16>
suggests, science is a collection of abstract maps of the world, not a
substitute for our own experience of the world (our own intuitive map). 16
<http://archinte.ama-assn.org/issues/v161n21/rfull/#r16>  Each specialized
map must omit everything that is irrelevant, out of scope, and out of scale.
What is the result? Science does not deny God, miracles, and the like;
rather, it merely neglects them. Further, the maps of science can never
"exhaust the original itself" so that although a "map-world may show joy and
sadness, hatred and love, it never can actualize them. . . . For the same
reason it is impossible that God would occur as an entity on a map" (italics
ours). The important message is to stop fighting the maps (and this includes
scientists who "trust their own maps more than the world itself" as well as
"people wanting to use them for unwanted destinations"). Science cannot
actualize our spirituality, so why do we ask this of it?



CONCLUSIONS



In chapter 17 of the Book of Exodus (KJV), Moses must confront one of many
potential rebellions by the Israelites, this one prompted by a lack of
water. After smiting the rock and producing the water, Moses names the place
Massah, the Hebrew word for "trial." Verse 7 tells the story: "And he called
the name of the place Massah . . . because they [the Israelites] tempted the
Lord, saying, Is the Lord among us, or not?" Later, in the Book of
Deuteronomy where many of the Jewish laws are explicated, this event carries
enough weight to warrant its own command: "Ye shall not tempt the Lord your
God, as ye tempted him in Massah" (6:16, KJV). And much later, when Yeshua
is having his visions in the wilderness and wonders whether God's angels
would actually bear him up in their hands if he leaped from a pinnacle of
the temple, he chastises his beguiler with these very words: "It is said,
Thou shalt not tempt the Lord thy God" (Luke 4:12, KJV).
The lesson of Massah is that God cannot be compelled by our research
designs, statistics, and hypotheses to answer our demand, "Is the Lord among
us or not?" Massah makes it clear that our intercessions must be a matter of
faith and trust in God, of putting our hope in God, of knowing we are part
of God no matter what the outcome in our experience of the physical world.
As a metaphor for the testing of distant prayer through the scientific
method, Massah tells us not only that God should not be tested but, more
important, that God cannot be tested. 41
<http://archinte.ama-assn.org/issues/v161n21/rfull/#r41> , 42
<http://archinte.ama-assn.org/issues/v161n21/rfull/#r42>  As Sloan and
Bagiella 40 <http://archinte.ama-assn.org/issues/v161n21/rfull/#r40>  have
written, mixing experimental method with faith degrades both concepts. We do
not need science to validate our spiritual beliefs, as we would never use
faith to validate our scientific data.



Author/Article Information


John T. Chibnall, PhD
Department of Psychiatry
Saint Louis University School of Medicine
1221 S Grand Blvd
St Louis, MO 63104
(e-mail: [log in to unmask] <mailto:[log in to unmask]> )

Joseph M. Jeral, MD
Washington, DC

Michael A. Cerullo, MD
Lexington, Ky


We are indebted to Jennifer Accardo, MD, for her critical insights.




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FULL TEXT <http://archinte.ama-assn.org/issues/v160n12/ffull/ilt0626-2.html>
|   PDF <http://archinte.ama-assn.org/issues/v160n12/fpdf/ilt0626.pdf>   |
MEDLINE
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God, prayer, and coronary care unit outcomes: faith vs works [letter]?
Arch Intern Med.
2000;160:1877.
FULL TEXT
<http://archinte.ama-assn.org/issues/v160n12/ffull/ilt0626-16.html>   |
PDF <http://archinte.ama-assn.org/issues/v160n12/fpdf/ilt0626.pdf>   |
MEDLINE
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Hammerschmidt DE.
Ethical and practical problems in studying prayer [letter].
Arch Intern Med.
2000;160:1874-1875.
FULL TEXT
<http://archinte.ama-assn.org/issues/v160n12/ffull/ilt0626-10.html>   |
PDF <http://archinte.ama-assn.org/issues/v160n12/fpdf/ilt0626.pdf>   |
MEDLINE
<http://www.ncbi.nlm.nih.gov/htbin-post/Entrez/query?db=m&form=6&Dopt=r&uid=
10871992>


Edward E. Rylander, M.D.
Diplomat American Board of Family Practice.
Diplomat American Board of Palliative Medicine.