The Problem of Theodicy and Religious Response to Cancer

Journal of Religion and Health, Vol. 36, No. 1, Spring 1997 The Problem of Theodicy and Religious Response to Cancer VINCENT D. MOSCHELLA, KRISTIN R. PRESSMAN, PETER PRESSMAN, and DAVID E. WEISSMAN ABSTRACT: The authors studied the religious response to cancer in a group of hematology/ oncology-clinic patients. Method: Patients (N = 45) were surveyed with a self-report questionnaire. Five items were designed to reflect the five major categories of theodicy or modes of reconciling suffering with a morally good God. Results: Of the 45 patients, in response to their illness, 67% (N = 30) increased amount of prayer, 51% (N = 23) gained faith, and 16% (N = 7) increased the frequency of church attendance. The majority of patients across all levels of religious belief endorse a theodicy that claims God has a reason for their suffering, but this reason cannot be explained or understood. Conclusions: Religious cancer patients intensify their religious belief and practice in response to their illness. Despite the elusiveness of an explanation for their suffering in religious terms, patients remain confident in their faith. There is abundant evidence that religion may be a clinically significant source of personal strength for those adjusting to medical illness in general1.2 and cancer in particular.3 4 Notably absent from this body of research are data that specifically illuminate the mechanisms by which benefits may accrue to those holding religious belief. One such mechanism is broadly encompassed by the term "theodicy." Theodicy was first used in the seventeenth century;5 it is defined as the effort to reconcile God's power and justice with the reality of suffering.67 The present study is an attempt to test the established categories of theodicy outlined in Western theological tradition83 against the clinical reality of theodicy. We surveyed religious belief, practice, and theodicy strategies in a sample of adults who identified themselves as holding religious beliefs and who were receiving treatment in the hematology/oncology outpatient clinic of Vincent D. Moschella, J.D., M.A., is adjunct faculty and clinical ethics consultant for the Center for the Study of Bioethics at the Medical College of Wisconsin. Kristin R. Pressman, M.D., is a house staff physician in the Department of Family Medicine at the University of Wisconsin- Madison. Peter Pressman, M.D., is a house staff physician in the Department of Internal Medicine at the University of Wisconsin-Madison. David Weissman, M.D., is a faculty scholar in the Project on Death in America, Soros Foundation. 17 C 1997 Blanton-Peale Institute

18 Journal of Religion and Health a large Midwestern general medical hospital. "Religious belief refers to the acceptance of a benevolent deity and "practice" is defined by frequency of church attendance.'" Methods Subjects were 45 patients recruited from the outpatient nematology/oncology clinic of the John L. Doyne Hospital, Milwaukee, Wisconsin. A total of 69 patients were consecutively invited to participate in the study. Eighteen patients refused, and 7 declared themselves as not religious and were considered not to have met inclusion criteria for this study. Subjects averaged 54.8 years of age. All subjects were diagnosed with cancer (23% with breast cancer, 15% with leukemia, 15% with lung cancer and others) and most were receiving chemotherapy, radiotherapy or both. All subjects gave informed, written consent to participate in this study which was approved by the Institutional Review Committee of the Medical College of Wisconsin. Subjects were surveyed with a self-report questionnaire that was developed for inclusion in this study and organized around the Index of Religiousness." The Index of Religiousness is a three-item measure of the personal importance of religion. The first item asks about attendance at religious services. The second item requests subjects to rate perceived religiousness (very religious; somewhat religious; not very religious). The third item asks to what degree religion (or God) is a source of strength and comfort. In addition to demographics, other items ask subjects for assessment of illness impact on their pre-illness frequency of church attendance, prayer, and level of faith in God. Categories of theodicy (from theology) are probed by items that ask subjects whether they believe their suffering is God's punishment for sinful behavior, whether they will be a better person as a consequence of their suffering, whether a reward for suffering will come in heaven, whether God has a reason for suffering that cannot be explained, and whether by suffering with illness one shares in the suffering of Christ. Results Of the 45 surveyed subjects, 42% (N=19) described themselves as very religious; 49% (N = 22) saw themselves as somewhat religious; 9% (N = 4) were not very religious; 38% (N= 17) were Catholic; 51% (N = 23) comprised other Christian denominations; and 11% (N = 5) declared no formal religious affiliation. Of all 45 patients, in response to their illness, 67% (N = 30) increased the amount of their prayer, 51% (N = 23) gained faith, and 16% (N = 7) increased frequency of church attendance. In response to their illness, 27% (N = 12) of the very religious subjects re-

Vincent D. Moschella, Kristin R. Pressman, Peter Pressman, and David E. Weissman 19 ported that they prayed more, 13% (N = 6) had no change in their amount of prayer, and only a single subject (5%) reported a decrease in prayer. Of the "somewhat religious" 73% (N = 16) stated that they prayed more in response to their illness; 27%' (N = 6) reported no change in amount of prayer, and no subjects prayed less. Of the four subjects describing themselves as not very religious, one increased amount of prayer, and the remaining three reported no change. On the issue of faith, 63% (N= 12) of the very religious gained faith, 37% (N = 7) reported no change, and none lost faith in response to their illness. Of the somewhat religious, 45% (N = 10) gained faith, 55% (N=12) had no change, and 5% (N = 1) lost faith. Of the not very religious, one of the four subjects gained faith, with the other three having no change. On church attendance, 21% of the very religious (N = 4) had increased frequency of attendance; 74% (N=14) had no change; one subject had lower attendance which he attributed to physical consequences of his cancer. Of the somewhat religious, 14% (N = 3) increased their church attendance, 82% (N=18) had no change, and 5% (N = l) decreased attendance, again secondary to physical limitations imposed by constitutional symptoms of cancer. Of the not very religious, all subjects (N = 4) reported no change. When the individual demographic and Index of Religiousness items of the survey were correlated with the five theodicy items, only the item positing that God has a reason for suffering that cannot be explained was significantly associated with self-report of religiousness across all levels (F = 9.03, p<.01). Discussion The results of the present study offer support for the notion that religious cancer patients intensify their religious belief and practice in response to their illness. This finding is certainly not surprising; neither is the observation that those who described themselves as somewhat religious demonstrated the largest changes. What does seem surprising is the endorsement of the one category of theodicy that offers no compensating redemptive or soothing elements or means for reducing the dissonance between a morally good God and the reality of suffering. The answer to the questions "Why me, God?" and "Why do bad things happen to good people?" appears to lie in the Old Testament proposition that mere mortals cannot understand God's workings and must defer that understanding with pure faith.12'13 Larger and more representative studies should seek to enroll more ethnically and religiously diverse patients, employ a matched comparison group of patients who are not religious, and administer measures of severity of illness or functional status and depression in order to learn more about coping in these groups. Categories of theodicy might well continue to be inventoried and tested, with development of an instrument for which construct validity and reliability can be demonstrated.

20 Journal of Religion and Health This pilot study contributes to the body of literature demonstrating the importance of religious belief and practice in studying psychosocial aspects of medical/surgical illness. It specifically proposes that one mechanism by which religious patients with cancer adjust to their illness is a theodicy that offers only faith as an answer to the question of suffering. References 1. Waldfogel, S, Wolpc PR., "Using Awareness of Religious Factors to Enhance Interventions in Consultation-Liaison Psychiatry." Hospital & Community Psychiatry 1993; 44, pp. 473-477. 2. Muthny, F.A. Bechtel, M. Spaete, M.. "Lay Etiologic Theories and Coping with Illness in Severe Physical Diseases: An Empirical Comparative Study of Female Myocardial Infarct, Cancer, Dialysis and Multiple Sclerosis Patients." Psychotherapie, Psychosomatik, Medizinische Psychologie 1992; 42, pp. 41-53. 3. Ginsburg, M.L., Quirt, C., Ginsburg, A.D., and MacKillop, W.J., "Psychiatric Illness and Psychosocial Concerns of Patients with Newly Diagnosed Lung Cancer." Canadian Medical Association Journal 1995;152, pp. 701-708. 4. Pressman, P., Larson, D.B., Lyons, J.S., and Humes D., "Impact of Religious Belief on Psychological Distress." Psychosomatics 1992;33, p. 470. 5. Voltaire, Candide. Ed. Adams, R.W. New York: W.W. Norton, 1966. 6. Durant, W. and Durant, A., The Age of Louis IV. New York: Simon & Schuster, 1963, p. 6"3. 7. Campbell, C.S., "Religion and Moral Meaning in Bioethics." Hastings Center Report 1990; pp. 4-10. 8. Green, R.M., "Theodicy" in The Encyclopedia of Religion, vol 14. New York: Macmillan, 9. Kreeft, P., A Summa of the Summa. San Francisco: Ignatius Press, 1990. pp. 204-207. 10. Willets, RK., Crider, D.M., "Religion and Well-being: Men and Women in the Middle Years." Review of Religious Research 1988; 29, pp. 281-292. 11. Zuckerman, D.M., Kasl, S.V., and Ostfeld, A.M., "Psychosocial Predictors of Mortality Among the Elderly Poor." American Journal of Epidemiology 1984;119, pp. 410-422. 12. Job 9:11. 13. Job 38:4.

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