Explore - Neural and Cognitive Basis of Spiritual Experience

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HYPOTHESIS

NEURAL AND COGNITIVE BASIS OF SPIRITUAL EXPERIENCE: BIOPSYCHOSOCIAL AND

ETHICAL IMPLICATIONS FOR CLINICAL MEDICINE
James Giordano, PhD,1# and Joan Engebretson, DrPH2
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The role of patient spirituality and spiritual/liminal experi-nce(s; SE) in the clinical setting has generated considerablequivocality within the medical community. Spiritual experi-nce(s), characterized by circumstance, manifestation, and inter-retation, reflect patients’ explanatory models. We seek to dem-nstrate the importance of SE to clinical medicine by illustratingiological, cognitive, and psychosocial domains of effect. Spe-ifically, we address where in the brain these events are processednd what types of neural events may be occurring. We posit thatxisting evidence suggests that SE can induce both intermediateevel processing (ILP) to generate attentional awareness (ie, “con-ciousness of”) effects and perhaps nonintermediate level pro-essing to generate nonattentive, subliminal (ie, “state of”) con-
ciousness effects. Recognition of neural and cognitive (
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16 © 2006 by Elsevier Inc. Printed in the United States. All Rights ReserISSN 1550-8307/06/$32.00

echanisms is important to clinicians’ understanding of theiological basis of noetic, salutogenic, and putative physiologicffects. We posit that neurocognitive mechanisms, fortified bynthropologic and social contexts, led to the incorporation ofE-evoked behaviors into health-based ritual(s) and religiousractice(s). Thus, these experiences not only exert biologicalffects but may provide important means for enhancing pa-ients’ locus of control. By recognizing these variables, we advo-ate clinicians to act within an ethical scope of practice as ther-peutic and moral agents to afford patients resources toccommodate their specific desire(s) and/or need(s) for spiritualxperiences, in acknowledgement of the underlying mechanismsnd potential outcomes that may be health promotional.

Explore 2006; 2:216-225. © Elsevier Inc. 2006)

NTRODUCTIONver the past decade, there has been considerable multidisci-

linary interest in spiritual experience and its possible role inuman health.1 In mainstream and many complementary med-

cal approaches, secular, and in certain instances, nonsecularpiritual practices are being viewed as potentially positive influ-nces on patients’ (at very least, subjective) wellness.2

However, there is considerable equivocality regarding the im-ortance and/or degree of enfranchisement that clinical medi-ine should maintain toward spirituality. These range acrossiametrically opposing viewpoints, from advocacy of clinicians’omplete acceptance and participatory involvement in their pa-ients spirituality3,4 to a more pragmatic stance that disregards oregates the importance of spiritual issues or effect(s) in the clin-

cal scenario.5 Poised somewhere in between is an ambiguouseutrality that is somewhat polarized at its borders; on one end,uch neutrality confers benign acceptance, whereas, on thether, it may represent implicit rejection.6 Hall and Curlin7

aintain that even such neutrality regarding patients’ spiritual-ty (and by extension, religiosity) is, in practicality, impossiblend intellectually undesirable.

Center for Clinical Bioethics, Georgetown University Medical Center,ashington, DCSchool of Nursing, University of Texas-Houston Health Science Cen-

er, Houston, TXupported in part by a Hunt-Travis foundation grant (to J.G.).

Corresponding author. Address:000 Reservoir Rd, Washington, DC 20057.

In this paper, we argue that it is important for clinicians toecognize patients’ spirituality as an important biological, psy-hological, and social variable that can potentially affect theoetic (ie, cognitive) experience and perhaps physiological as-ects of well-being. We attempt to illustrate the putative neuralubstrates of spiritual experiences and frame these within anthro-ologic contexts to demonstrate the salutogenic role such neu-ocognitive events manifest within individuals, societies, andultures. Last, we argue that the ethical foundations of medicalractice obligate the clinician to acknowledge the basis and ef-ect(s) of these variables. In recognizing this, we advocate thathe clinician, as a steward of knowledge and therapeutic andoral agent, act prudently to enable their patients’ access to

hose resources that best serve the good of their spiritual needs.

ONTEXTS OF SPIRITUAL EXPERIENCE(S)pirituality and religion are not inherently identical, and theincorrect) semantic interchangeability of these terms may be aource of philosophical and practical difficulty for many clini-ians. Establishing more appropriate definitions of spiritualitynd religion thus becomes an important step in helping to clarifyow these may play a role in patients’ experience and thereby

dentify how clinicians may potentially address these domains toacilitate positive clinical outcomes.

A number of definitions of spirituality exist; however, all ad-ress a universal aspect of the human condition. With etymo-ogical roots in the Hebrew word for “breath,” it implies some-hing intrinsic to life.8 Connelly and Light examined severalefinitions of spirituality, finding several common attributes
ncluding the following: the essential; the core; and the central,
ved EXPLORE May 2006, Vol. 2, No. 3doi:10.1016/j.explore.2006.02.002

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ntegrating dimension or domain of life or that which bringsignificance, purpose, meaning, and direction to peoples’ lives.9

An additional aspect, with relevance for healthcare is theoncept of the spiritual experience. Spiritual experiences arerequently associated with religious events and/or circum-tances. However, the phenomenon itself is definable in sec-lar contexts, and terms such as liminal or transliminal andublime and/or ecstatic occurrences could be used instead,hereby preventing any overt religious connotations whenircumstantially inappropriate. Irrespective of the term(s)sed to describe the occurrence, such experiences are an al-ered state of consciousness that may be the result of activa-ion of distinct neural mechanisms by external and/or inter-al stimuli. Phenomenologically, they generally consist of anxtraordinary conscious experience with both strongly per-eived subjectivity and intentionality� (although frank objec-ification may not occur, as in the sublime experiences in-uced through certain Buddhist meditative practices10).hese experiences often assume ineffable and somewhat sub-

ectively metaphysical characteristics. It is not uncommon foreople to have such experiences around birth and death anduring illness, trauma, and extreme emotions or suffering;hus, health problems often precipitate their occurrence.11

lthough such experiences may be interpreted through reli-ious beliefs, this interpretation may be more confusing if thendividual is not a member of a religious group that hasemiotics to provide adequately context or meaning to thevent.

The word religion stems from the meaning “to bind together.”12

hus, religion, by definition, refers to a community aggregate, tohich an individual maintains a sense of belonging through ideasf beliefs, practices, ethical teachings, and cosmologies within spe-ific sociocultural institutions and traditions. Spiritual issues maynd expression through and be codified by social institutions thatring together groups of people to share collectively a belief systemnd practice its disciplines. As a salutory social practice, this processlso serves to form a unifying connection among its members.13

Terminology, at least in part, may indirectly affect social andedical attitudes toward the nature and value of these experi-

nces and practices. For the clinician, an understanding of thehenomenology, neural correlates of spiritual experience andhe relation to the social, cultural, and psychological domains ofeligion, may be helpful in depicting these variables in contextsore resonant to medical practice(s).

�Terms such as “intentionality,” “‘desire,” and “will” are not used in

he “folk psychological” sense to connote some specific contextual

eaning that implies adherence to a particular theoretical orientation to

concept of “mind.” Rather, these terms are used to explain the cogni-

ive dimension(s) and effect(s) of neural events in ways that are resonant

o familiar concepts and constructs of brain-mind function(s). See

undt W. Elements of Folk Psychology: Outlines of a Psychological History of

ankind. Schaub EL, trans. London: George Allen and Unwin; 1916,

nd Churchill, Paul. Eliminative materialism and the propositional atit-

udes. In: Lyons W, ed. The Disappearance of Intropsection. Cambridge,

A: MIT Press; 1986. g

eural Basis of Spiritual Experience

AXONOMY AND PHENOMENOLOGY OF SPIRITUALXPERIENCEe have recently evaluated spiritual experiences from a database

f over 300 reports (Wardell D, Engebretson J. Taxonomy of apiritual experience: a qualitative analysis of healers. Journal ofeligion and Health. 2006, in press). Through a taxonomic anal-sis, three domains were identified: the circumstances underhich the experience occurred, the manifestations of the expe-

ience itself, and the interpretation of the experience. The cir-umstances include both external and internal contexts. Thexperiences were manifested through various modes of aware-ess, and both observable as well as symbolic phenomena wereescribed. The cognitive interpretation reflects individuals’ priornd current circumstance and resonance to sociocultural orien-ation. Thus, the spiritual experience assumes qualitative “mean-ng” by virtue of its circumstance and manifestation. The quali-ative nature of the spiritual experience is based on conditions ofanifestation that influence both the actual subjectivity and

ubsequent “levels” of interpretation of the subjective event.

HE NEUROBIOLOGY OF SPIRITUAL EXPERIENCEhe emergent field, known somewhat provocatively as “neuro-

heology,” explores the relationship between spirituality, spiri-ual experience(s), and neurological processes.14 A rapidly ex-anding area, the neural substrates putatively mediating spiritualxperiences have been elucidated by brain-stimulation experi-ents, neuroimaging studies, and evaluation of the neuroanat-

my of pathologic conditions in which spiritual experiences arerominent.† Early experiments by Persinger15,16 and Cook andersinger17 induced conscious experiences with strongly spiri-ual “feeling” and contexts through transcranial electromagnetictimulation of the (left and right) temporal lobes. More recently,ewberg et al have used single photon emissions’ computerized

omography (SPECT) to examine regional brain activation ineditative and religious states.18 These studies have revealed

hat differential activity in several structures including the tem-oral lobes, cingulate gyrus, superior parietal cortices, and rightateral prefrontal cortex (RLPFC) appear to subserve spiritualxperience(s).18-23

HE HIERARCHICAL PROCESSING MODELefore discussion can delve into the postulated neuroscience ofpiritual experience, it is important to define operationally thoseeural mechanisms involved in consciousness.‡ The contempo-

†The reader should draw their own conclusions about the “meaning”

f this circuitry relevant to spiritual experience(s). Such meaning will

eflect cultural, social, and spiritual and/or religious orientations and

eliefs. We do not intend or desire to superimpose on or oppugn any

uch individual beliefs. Rather, we maintain that the theoretical models

nd concepts presented herein do not refute any particular orientation

ut, instead, serve to enhance further speculation, inquiry, and dis-

ourse.

‡The understanding of how the physical substrate that is the brain

enerates consciousness represents what David Chalmers calls the “hard

217EXPLORE May 2006, Vol. 2, No. 3

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ary notion of conscious processing is built on the work ofackendoff from the late 1980s.24 Based upon the psychologicalrocesses and the function of sensory and perceptual systems,ackendoff developed a general model that “constructed” a the-retical conceptualization of tiered neural activity throughhich discrete psychological (ie, cognitive) events were assem-led. Although the specifics of the Jackendoff model have beenebated, and some refuted entirely, the conceptual model ofierarchical processing has remained valid and, as matter of fact,as been considerably substantiated by recent advances in neu-oscience.25

Using the Jackendoff model as a basic pediment, there isonsiderable evidence to demonstrate that lower levels of neuralrocessing (ie, extero- and interoceptive sensory data) primarilyncode first-stage sense data that “define” discrete, local charac-eristics about the stimulus but do not impart perceptual orognitive “valence” to it. Such mechanisms primarily occur athe level of the brainstem. At the intermediate level, these inputsre combined and conjoined to larger field representations bothithin the brain and to those brain areas that are activated byhanges in bodily state. Thus, at the intermediate level, neuralrocessing involves a more global activation of neural substrateso produce an identifiable “brain-mind” state, engage attentionalocus, and feed these inputs toward working memory so as toncode their effect. This intermediate level of processing is sub-erved by a number of brain areas, including the anterior andedial cingulate, associative cortex, insula, and regions of the

arietal and temporal cortices. Prinz,25,26 Crick and Koch,27 andees et al28 support that such intermediate level processing

ILP), coupled to attentional focus, is the basis for “directed”onsciousness (ie, “consciousness of” an event and/or its inter-al effect[s]). Higher, tertiary-tier processing involves recogni-ion of pattern similarity, matching to sample and advancediscrimination. These functions are mediated by the rostral an-

roblem” of both neuroscience and neurophilosophy (see Chalmers62).

hus, although consciousness can be operationally defined to some

xtent, the nature of “what” is being defined and “how” this is produced

y or within the brain remains the focus of considerable debate. Theo-

etical and philosophical positions range from the dualist perspectives

eg, complementarity of mind and brain, property dualism) to a monist,

aterialism (eg, eliminativism, absolute physicalism), with perspectives

hat are somewhat “in between” (eg, emergentism, nonreductive physi-

alism). In addition, there is considerable debate whether this “hard

roblem” can be solved. Daniel Dennett contends that consciousness

epresents an as yet unresolved property of neural function and views an

xpanding epistemic capitol as being the step stone to solving the con-

ciousness “problem.” In contrast, Colin McGinn believes that we have

eached a point of “cognitive closure” in attempting to understand the

mystery” of consciousness, and, thus, it will interminably remain in-

omprehensible. A complete discussion of this topic is beyond the scope

f this paper. For a concise review, see Lyons W. Matters of the Mind NY:

outledge; 2001. For more detailed discussion of particular perspectives,

ee Dennett D. Sweet Dreams: Philosophical Obstacles to a Science of Con-

ciousness. Cambridge, MA: MIT Press; 2005; McGinn C. The Problem of

wonsciousness: Essays Towards a Resolution. Oxford: Blackwell; 1991.

18 EXPLORE May 2006, Vol. 2, No. 3

erior cingulate gyrus, ventromedial prefrontal cortex and maylso involve regions of the inferior and/or medial temporal cor-ices. Although these areas may contribute to perceptual abilitieshat facilitate object and stimulus distinction and are participa-ory in sharpening memory formation, they do not seem to beirectly involved with attentive focus and “consciousness of”ut, rather, just “add” distinguishable elements to the neuraletwork effects.25,26,29

How might spiritual experiences engage and/or be the resultf these neural mechanisms? External and/or internal environ-ental input to (first tier) ascending sensory and reticular path-ays can engage the thalamus to activate the cingulate and insuland stimulate the amygdala. This second-tier activation can oc-ur without engaging attentional focus, thus producing a sub-iminal “conscious state” of the sense data and of some basalmotional content that reflects differential neurochemical activ-ty in distinct amygdalar regions.25 Recent studies have sug-ested that the left amygdala subserves positive emotions andrive states, whereas the right amygdala appears to mediate moreonnotatively negative states.30 However, with continued rightmygdalar activation, the left amygdala may become collaterallyngaged, thereby producing pleasurable emotions, feelings, andrives31-33 that are often consequential to periods of intenseistress and (physical or emotional) suffering.Robust stimulation of this system engages attentional focus

nd activates the deep temporal lobe(s) and/or their input to theosterior prefrontal cortex, parahippocampal gyri, and hip-ocampus to engage working memory and appears to subserveconsciousness of” an internal or external event or condi-ion.25-28 The amygdalar-septohippocampal neuraxis is impor-ant in linking consciousness of emotions and drive states toreextant memories and new memory formation34 (with someifference in positive and negative memory consolidation toight and left hippocampi, respectively33). This may be the basisf situational objectification34 and may contribute to the in-olvement of declarative memory in emotionally contextual be-ief states.34,35

The differential activation of left or right temporal corticeslso appears to contribute to components of the spiritual expe-ience. In the majority of individuals, the left temporal cortex isperative in establishing the representational sense of self-aware-ess. In addition, communicative and primary linguistic capac-

ty is localized within this region, thereby establishing neuralonnectivities that may subserve both the ideative and commu-icative components of self-representation.36,37 In contrast, theight temporal lobe functions in nonprimary communicationbilities (eg, prosody, linguistic intent),38 and basal (38-40 Hz)lectrical activity within the right temporal field has been hy-othesized to be contributory to the subjective awareness of thenternal brain-mind state.39-41 The temporal lobes appear tounction in concert with left and right superior parietal corticeso establish the boundary between contained, somatic self-per-eption and the external environment.42

In summary, external (and internal) environmental events areelectively attended to stimulate differentially the cingulatednd either the left amygdala (to produce positive emotions) oright amygdala (to produce strongly negative emotions that may,
ith continued and durable activation, subsequently engage the
Neural Basis of Spiritual Experience

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ontralateral amygdala to evoke feelings of elation). Amygdalarutput engages the parahippocampal and hippocampal regions,inking the emotional response to both declarative and emotive

emory and framing it within the current circumstance(s). Dif-erential activation of the temporal lobes may produce enhancedinguistic outflow or facilitate a linguistic component to thexperience. Discontinuity in the coordination of the left andight medial temporal cortices may produce sensations of a phys-cal (or nonphysical) “presence” that, through concomitantmygdalar-hippocampal activation, is often cognitively con-oined to emotional and/or memory states and may be con-trued in personal (eg, presence of relatives or conspecifics),ultural (eg, presence of archetypal figures/characters), and/oreligious (eg, deific presence) contexts. Such strong limbic acti-ation, together with the focal activity of the RLPFC appears tongage selectively the temporal lobe(s) and reduce the activity ofhe superior parietal cortical fields, leading to a distortion inoth somatosensation and perceived relation to the externalnvironment (eg, feelings of detachment or infinity). This tenta-ive neuraxis, summarized by Table 1, is schematically depictedn Figure 1.

It is of interest to note that individuals suffering from tempo-al lobe epilepsy (TLE) may experience many of these sameubjective phenomena, including feelings of “presence of anxistential other,” situational detachment, altered sensorium,nd change in subjective consciousness.43,44 Spread and diffu-ion of the ictal discharge to adjacent brain areas lead to progres-ive involvement of brain loci subserving somatosensation, lin-uistic capacity, and flow.45 In addition, many patients with TLEnd temporal lobe lesions manifest excessive spirituality or reli-iosity.46,47 Taken together, these convergent lines of evidencetrongly suggest that a discrete neuroanatomical pathway is in-olved or may directly subserve many of the components ofpiritual experiences.

Apart from such pathologic examples as patients sufferingLE, the activation of these neurobiological substrates seems toe capable of producing beneficial physiologic effects.48,49 The

ongitudinal work of Benson50,51 and Benson and Dusek52 hasemonstrated the efficacy of liminal, meditative states (with con-omitant subjectively spiritual experience) and the contributionf these events to the placebo response. The recent studies oftefano et al53 and Lazar et al54 have indicated that “downstreamathways” are likely activated by these neuraxes. Interestingly,n important variable in the induction of neurophysiologicechanisms subserving both spiritual events and placebo re-

ponse(s) seems to be the relative enfranchisement, or “belief,”f the patient.55,56 Studies have shown that the RLPFC plays arucial role in the expectational and belief processes crucial tohe induction and magnitude of particular patient-centered andlacebo-type effects.21-23,56 This is consistent with the work of8 and d’Aquili and Newberg23 that demonstratedtrong RLPFC involvement in the attentional dimension(s) spir-tual responses. Thus, it appears that these neural systems areapable both of producing/subserving the cognitive dimensionsf spiritual experiences and engaging “top-down” physiologicechanisms. Such proverbial “mind-body” interactions have

ong been known57-59 and, more recently, have been the basis of t


tudies in psychoneuroendocrinology and psychoneuroimmu-ology.From such findings, we are inclined to say that the mind event

ie, the spiritual experience) is representative of a brain event (ie, thectivation of specific neural pathways and mechanisms by externalnd/or internal means), thereby assuming that mind is in some way direct process of the neurological activity of the brain.60,61 Al-

able 1. Neuroanatomical Substrates Putatively Subserving Spiritual/iminal Experiences

Neural Substrate Putative Function

rainstem reticular formation Initial arousalSubsequent suppression during

liminal stateidbrain grey region(s) Opioid-mediated effects:

Emotionality, euphoria, and painsuppression

ubcortical regionsAnterior/medial cingulate Perceptual domains of processingInsula

ortical regionspecific sensory cortices Sensory attendance during inductive

phaseuperior parietal cortex Somesthetic awareness; suppression

may produce alterations in senseof boundary

emporal cortexLeft temporal cortex Primary communicative areas

May subserve linguistic outflowduring liminal events/experiences

Representational sense of self-awareness

Right temporal cortex Secondary communicative regionPutative source of 38-40 Hz

component hypothesized to becontributory to conscious state

edial temporal cortex Discontinuity between L/R temporalcortices may produce sensationsof physical or nonphysical“others.” or nonphysical “others.”

LPFC Attentiveness, focusExpectation, “belief”

imbic structuresAmygdala

Left amygdala Emotionality: putative positive noesisRight amygdala Emotionality: putative negative noesis

Hippocampus Memory inductionEmotional content/construct of

memoryDifferential engagement of

declarative or emotional memory(ie, belief)

efer to text for detailed description; refer to references 10,14-40.

hough a viable enough position, there are two issues that have been


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onsidered to complicate this philosophically materialist/physical-st approach. First is that it appears that actual subjective (spiritual)xperience is, on some level, necessary for the induction of the sub-equent (physiological) effects. This consideration then leads to the

igure 1. Schematic diagram of neural structures putatively subservs explained in text, provocative input may include external and/or innd others) and/or rituals (eg, prayer). These may serve as “bottom-uILP), cognitive awareness of the summative effects of engagementttentional mechanisms (to evoke “consciousness of” the event) andonsciousness events) as well. Perception of these neural events mayo exert positive salutogenic effects and may be important for the indutop-down” processes are illustrated in bold arrows in the Figure (see tubstrates with demonstrated involvement in spiritual experience(s); reevel processing; RLPFC, right lateral prefrontal cortex.

econd, which is that the brain-mind condition(s) induced by expe- i


ience itself appears to represent a distinct “state of” consciousness,s well as an event that we can be “conscious of.” Certainly, thepiritual experience fulfills many of the requisite criteria for a con-cious event and/or state. It is subjective; it has structure; it is famil-

ensory, cognitive, and physiologic sequelae of spiritual experience(s).sensory stimuli that are produced by specific behaviors (meditation,

ody-brain/mind events. At the intermediate level of neural processingis neuraxis produces distinct conscious experience(s) by engaging

engage higher level, nonattentional mechanisms (to evoke “state of”ponsible for the qualia of conscious experience. These events appear

of hierarchical neural processes and physiologic manifestations. Suchr details, refer to Table 1 for summary of proposed functions of neuralreferences 10,14-40). ILP, Intermediate level processing; HLP, higher

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ange of attention; and it has self-situatedness, possesses varyingegrees of unified form, and manifests some dimension of pleasurer unpleasantness.62

We argue that these proposed complications can be recon-iled to the neurobiological model as processes that reflect pro-ressive activation of “bottom-up,” “collateral,” and “top-down”eural networks. These generate distinct patterns of neurologicalctivity (which produce distinct sense data and perceptual stateso feed forward and bridge the biological event(s) (ie, the brainvent) to a psychological effect (ie, a mind effect). According toearle,63 the unity of consciousness involves an integration ofultiple brain-mind events into a singular field of subjectively

pprehensible experience(s) relative to processes of both mem-ry and thought. Spiritual experiences appear to engage hierar-hical levels of brain function, from acquisition of purely senseata to the more extrapolative cognitive events of linking emo-ions and memories to expectation and/or contextual objectifi-ation(s). The cognitive and emotional characteristics of thisxperience both solidify such objectification (ie, places the ex-erience within the framework of relating the perceived self to annvironment or other agent) and organize this objectificationithin cognitive and linguistic domains that are consistent with

he epistemic and cultural orientation of the subjectiveself.”64,65

Last, the experience has definable, subjective conscious char-cteristics, its qualia. Although there is ongoing neurophilo-ophical debate about the existence/nonexistence and relativeeaningfulness of qualia,66-69 it is the qualia of the spiritual

xperience that are reported to contribute to individuals’ con-omitant subjective feeling of “well-being.”23,49-52 Whether epi-henomenal or a direct mental process, this may in some wayeflect the perception of the neurally evoked, conscious experi-nce itself as being pleasant (or not). In this light, the spiritualxperience can assume contextually noetic value. When consid-red in this perspective, even if considered as a solely neuralvent, its role as a fundamental, patient-centered response andts importance to perceptions of well-being and, therefore, self-ttribution of subjective “health” (ie, “feeling good”) becomeore readily apparent.§

NTHROPOLOGICAL PERSPECTIVESowever, an important unresolved issue remains: how did such

xperiences come to be such a fundamental part of the culturalepertoire of diverse social groups? We maintain that these experi-nces represent consciously recognizable events with subjectivelyelevant and potentially objective effects and salutogenic benefitsin certain instances). Humans may have recognized that particular

§We do not intend to make any suppositions or presumptions about

he possible “purpose” of the spiritual experience, even as a neural event.

ertainly, it is a matter of personal orientation and belief whether such

vents, and the neural circuitry that subserves them, are extero- or in-

eroceptively derived and what the derivational source of these events

ay be. For an interesting and provocative discussion of such possibil-

ties, see Newberg A, D’Aquili E, and Rause V. Why God Won’t Go Away:

crain Science and the Biology of Belief. New York: Ballantine Books; 2001.


xternal events (eg, circumstances, behaviors) may be capable ofrovoking positively noetic experiences (by engaging particulareuroanatomical substrates to induce mechanisms that are subjec-ively appreciable). In addition, such mechanisms may engage aascade of physiological events that may be both internally (ie, self)erceptible (eg, changes in metabolic state, relaxation, and others)nd produce changes in neurochemistry to elicit feelings of rein-orcement and reward.15-19,30-33 The sum of these hierarchicalvents could be a considerable change in multiple domains of con-ciousness (eg, attentional and nonattentional mental states), inhich the relation of the conscious state (ie, the neural events) and

ts qualia to an identifiable object or “other” might be framed withinhe environmental, sociocultural, and/or circumstantial context(s)f the subject.It has been suggested that the phylogenic development of the

uman brain has resulted in a predisposition for a fundamentalet of cognitive drives and desires as well as cognitive actions orneeds.”70,71 These fundamental cognitive need states can beummarized as the need for knowing, need for meaning, andeed to relate.71 Such cognitive needs may have had consider-ble influence on the complexity of both individual humanonsciousness and the dynamic nature of human socioculturalnteraction.72

Implicit to this viewpoint is that the neurological complexityf the brain predicates ongoing interpretive analysis (of bothxternal events and internal conditions) versus simple behavior-sm.73 If we approach human existence relative to ecologicalurvivability, the need to know and the need to relate, coupledith the advanced communicative capacity rendered by the

tructure of the brain, afforded the human species a considerabledvantage.74 If the spiritual experience can be considered anvent of consciousness, then its relative benefit to individuals incommunity could only be relevant if it were describable. This

s wholly consistent with the relationship of consciousness toanguage.62-64 Developing the linguistic capability to communi-ate what is “good” from what is “bad” in the environmentould have been a significant attribute to evolutionary suc-ess.74 Equally important would be the ability to linguisticallyommunicate the first-person experience of subjective states,specially those with profound (positive or negative) noeticalue. Early recognition of particular behaviors or exposure tonvironmental events that were capable of eliciting neurologicalechanisms that subserve definable, positive conscious (ie,

spiritual”) experiences may have had powerful influence in lightf their strongly subjective effects.75 The need to communicateuch feelings would have been relatively imperative on both anndividual and social level.76

However, even the most modern, sophisticated brain is not ca-able of describing the qualia of conscious experience in completelyaterialist or physical terms (only the most ardent eliminativistould describe their subjective conscious state in neurobiological

eferents). Thus, the social need to develop linguistic ability toescribe an event that is as phenomenologically meaningful as thatroduced by such neurobiological events within the context of thepiritual experience would almost naturally manifest a sense of in-entionality, be perceived as objectifiable, and thereby described inerms of its circumstance and manifestation. The human need to
reate rational sense of such internal experiences would lead to the

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evelopment of interpretive frameworks that were consistent withoth the epistemic scope and cultural bias of that time. Such epis-emologic measure was limited, and the level of explanation coulde seen as consistent with both the common understanding of theorld and a relative desire to manifest some operational level ofontrol over that environment. According to Kuhn, the humaneed for explanatory models is often satisfied even if explanationsre inadequate or incorrect.77 Thus, practices (such as rituals)volved to induce and preserve these (positively) noetic experiencesithin a level of meaning that was resonant within particular cul-

ures.78 Equally consistent is the hypothesis that the expressiveector of consciousness, language, is by its nature symbolic. 73 Atrong relationship exists between the state and foci of conscious-ess, the language used to describe these states and foci, and theocial reality in which these events occur.72-74 The nature of lan-uage to be symbolic is important in that it satisfies the human needo provide meaning, objectify the environment, and relate (both tothers as well as to construed superlative forces through whichesires for environmental control might be effected72,79).� The con-eptualization of this may have changed over time and may reflectumanity’s interaction with, and susceptibility to, both positivend negative environmental factors. Although there were certainspects of the environment that may have been controllable, manythers (plight, famine, disease, death) were not. Furthermore, aundamental negative experience is fear of the unknown. 72,73 Theevelopment of culturally symbolic archetypes is often built onocietally resonant explanations for and attempts to control un-nown domains of environment or existence.73,74 As such, thesexplanations satisfy the desire for intentional causation, in whichonscious representation and the reality of the external world are inome way consistently and meaningfully unified.63,64

With an increased need both to make sense of and to controlhe environment, there develops recognition that certain behav-ors and rituals may be able to invoke internal feelings of posi-ivity. This could produce an internalized locus of controlgainst an external environment that may have been viewed aselatively refractory to understanding or controllability. Discreteociocultural groups may have established disciplines to practiceechniques that were provocative for such noetically positivexperiences. The linguistics that supported these practices wouldaturally reflect common archetypes that were resonant to thepistemic framework of these respective groups. Therefore, weosit that organized religion(s) developed as a cultural frame-ork for the linguistic transfer of behaviors that would incurositive spiritual experiences and afford them interpretive mean-ng.

In an abstract sense, this could be considered to be a rudimen-ary approach to public health practice, in that it conferredehaviors that could produce “wellness” experiences within aroup of individuals. Uniform practice of these behaviors wouldeduce perceived health disparity by conjoining all members ofhe group in salutogenic activity and would serve a preventiveole in health practices (by reducing feelings of negativity thatere ascribed to “bad” or “evil” archetypes). The question arises,

�See also Wittgenstein L. Tractatus Logico-Philosophicus. Pears DF,

tcGuinness BF, trans. London: Routledge and Keegan Paul; 1961.


hen, of whether religion may serve a similar role in the modernedical setting.Further research is needed to derive a viable answer to this ques-

ion. However, an equally important question is the type and na-ure of studies that could best address this issue. Seemingly, thebest fit” would be a mixed methods approach. Built on a range andiversity of evidentiary frameworks that acknowledge both multiplend points and contributory processes in health and healing, suchtudies permit more complete assessment of both quantitative andualitative variables. This would allow for appreciation of patient-entered effects in observed outcomes, the knowledge of whichould potentially enhance the ability of the clinician to act moreully in the role of therapeutic agent.80

RACTICAL APPLICATIONSor many patients, declining health and/or confronting diseaseepresent events that both strip away an internal locus of controlie, produce a sense of “victimization”) and often expose them ton environment that may elude their linguistic capacity andasis of understanding (ie, “medicalization”). This perceived lossf control and increased level of unpredictable unknowns mighte contributory to the enhanced religiosity of the gravely ill,hronically diseased and aged.1,11 However, as discussed, reli-ion is just one means to incur spiritual experiences. It is impor-ant to recognize that the role of religious belief and practices tovoke the noetically (and perhaps physically) positive effects ofhe spiritual phenomenon may be assumed by a variety of otherehaviors and experiences by more secular patients.Irrespective of whether secular or nonsecular in orientation,

he spiritual experience is essentially composed of circumstance,nterpretation, and manifestation. As presented in Table 2, theseeflect biopsychosocial frameworks that exist in each particularatient and may provide insight into meaningful cognitive andocial contexts that affect individuals’ relative construct(s) ofellness and illness.81

Often, the basis and interactive nature of these factors are notamiliar to many clinicians, and such an applied approach mayequire a revision in medical scholarship, both in academia andt the bedside. How might this be accomplished? First, it isritical to acknowledge that spiritual experiences exist as neuro-ognitive phenomena and that these can potentially exert salu-ogenic and physiologic effect(s). This can help to establish ex-lanatory models that are bilaterally relevant to patient andlinician. This bilaterality enhances the patient-clinician interac-ion and may facilitate a more positive healing environment.econd, the clinician need not be an agent for the spiritualxperience9; however, in recognizing these effects as a possiblyelevant clinical variable in patients’ health, the clinician shoulde participatory in making resources available (and/or support-ng patients’ use of such resources). This further enhances theherapeutic relationship by promoting the patient as being aeciprocal partner in their own care. In addition, this avoidseutrality, which can often be a blind to trivialize the role ofxplanatory models and may contribute to nocebo effects.82,83

uch blinds may also allow the clinician to infuse subtly theireliefs on the patient.84 This may occur implicitly, connota-
ively, or explicitly but can exert profound paternalistic influ-

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nce to negate patients’ beliefs in both their healing resourcesnd in the therapeutic alliance.

On a somewhat deeper, more philosophical level, we arguehat the defined ends (ie, the telos) of medical practice are theendering of a right and good healing to those made vulnerabley disease, illness, and/or injury.85 To do what is right requiresechnical knowledge of the disorder and the treatment. How-ver, the “goodness” of care must be determined at four discern-ble levels, requires a somewhat broader knowledge of the pa-ient and their existential situation, and is more ethicallyomplex.86¶ The clinician must strive to (1) achieve what is

¶In part, this ethical complexity stems from divergent opinions of the

ature and/or possibility of “goods” that are universal, both within

edicine and societies. Although most are workingly familiar with the

Principlist” approach associated with Tom Beauchamp and James Chil-

ress (Principles of Biomedical Ethics, 5th ed. NY: Oxford University Press;

001), the perspective advocated in our work reflects a teleological,

irtue-based ethics that is built on a philosophy of medicine as espoused

y Edmund Pellegrino and the late David Thomasma (see Pellegrino85

nd Pellegrino andThomasma86). See also Gert B, Culver CM, Clouser

. Bioethics: A Return to Fundamentals NY: Oxford University Press;

997; and, for a contrary viewpoint: Veatch R. The impossibility of a

orality internal to medicine. J Med Philosophy. 2001;26:621-642, and

ngelhardt HT. The Foundations of Bioethics. 2nd ed. New York: Oxford

able 2. Biopsychosocial Domains Encompassed by Spiritual Expe-ience(s)

Biological Domains

Neural mechanisms/ substrates of spiritual experience (see Table1, Figure 1)

Extra neural substrates:Neuroendocrine regulationNeuroimmune regulation

“Top-down”-mediated physiological processessychological Domains

Noetic properties of spiritual experienceEmotional effects

Meaningfulness (contextual and symbolic)Resonance with explanatory knowledge/ modelsEnhanced internal locus of controlProperties of consciousness

SubjectivityIntentionalityTransparency to self

ocial DomainsCultural influences/expressionSecular/nonsecular orientationGroup/community connectednessEnvironmental influence(s)

efer to text for complete description; see references 48-55, 57-59, 81-83.

niversity Press; 1996.


iomedically good; (2) acknowledge the good for the specifichoices of the patient; (3) satisfy the humanitarian good of treat-ng the patient as a dignified human being; and (4) should, onome level, accommodate that good that defines the patient’sltimate and more deeply existential needs.86 Clearly then, thelinician is both a therapeutic and moral agent. Thus, we arguehat, to meet these four-fold obligations of beneficence, it ismportant (and perhaps imperative) that the clinician take anctive role in assessing the importance of their patients’ spiritu-lity in recognition of its biopsychosocial influence on theirealth. This does not imply that the clinician should participate

n spiritual domains of their patients’ care.84 To the contrary, weiew this as imprudent and believe that the clinician should notartake in their patients’ spiritually inductive practices becausehe deeply personal and individually unique nature of thesexperiences may be beyond the scope and tenor of the medicalelationship.9,87 However, the acknowledgment of patients’ spir-tual needs, understanding of the physiologic basis of spiritualxperience, and accommodation of patients’ desires for spiritualesources permit the clinician to assume an accepting stance and,n so doing, may fortify the clinician-patient relationship as aundamental domain of healing.

cknowledgmentshe authors thank Sherry Loveless for assistance on graphicrtistry.

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