Absence of Evidence

After reading my last post, my oldest son, who is about to graduate from medical school with high honors (if not from the school, certainly from his mother and me), sent me an email in which he was quite critical of the information from Dr. Chauncey Crandall, MD, which I so generously believed and repeated to my readers (if I have any besides my son).  After reading it, I decided he was right and that since I posted the information, I should post his revealing information as well. I have cut/pasted the bulk of his email for your benefit.

I’d caution you to be more skeptical of the information you receive from an online publisher.

“It is difficult to get a man to understand something, when his salary depends upon his not understanding it!” -Upton Sinclair

I agree wholeheartedly with the intent of the post and the feeling behind it, but I think you’ve had the wool pulled over your eyes by some fancy medical terminology. I haven’t found a copy of Dr. Crandall’s newsletter, but is sounds like either he’s grossly misrepresented the findings of the prayer studies, or you’ve misunderstood. There have been plenty of studies on prayer in medicine, because if it worked, we would do it. We do plenty of things that work – even if we don’t know exactly why or how – based off good evidence that they do. Prayer – when blinded to the intervention – is not one of them. That’s why you need to do much more than just pray, you need to let the people know you are praying for them (meditating, whatever your spiritual moment of choice may be). In fact, telling them you are praying for them and not actually doing it is arguably equally effective, albeit ethically dubious, and certainly more effective than praying for them but not telling them. Most of all, I’d recommend praying *with* them (if they are comfortable with that), as long as there are no ceremonies involving exposure to chemical or potentially infectious agents (ash, oil) and as long as proper hand-washing and infection control procedures take place before and afterward.

As for the post, the 150-person Duke “study” he referenced isn’t a study, it was a “feasibility pilot,” meaning they did a preliminary mini-study to see if doing a real study was practical. Here is the reference:

Krucoff MW, Crater SW, Green CL, Maas AC, Seskevich JE, Lane JD, Loeffler KA, Morris K, Bashore TM, Koenig HG. Integrative noetic therapies as adjuncts to percutaneous intervention during unstable coronary syndromes: Monitoring and Actualization of Noetic Training (MANTRA) feasibility pilot. Am Heart J. 2001 Nov;142(5):760-9. PubMed PMID: 11685160.

Their “Clinical Outcomes” portion of the Results section begins with this: “Rates of post-PCI ischemia, MACE, and ACE over the index hospitalization and 6-month mortality rates are shown in Tables V and VI. There were no significant differences between treatment arms.” In scientific terms, a “significant” difference means one that’s deemed not likely due to chance. This didn’t have any of those.

Saying that “only the patients that were being prayed for had lower complication rates” is downright misleading. Reading further in the study, it says that the prayer group had the lowest mortality *of the arms that got the special therapies* (prayer, imagery, touch therapy, and stress relaxation), but the “standard therapy” group (the ones randomized to receive no prayer or other intervention at all) had *no* deaths at 6 months out – none – whereas the prayer group had a morality rate of 3% (probably just 1 person, with such small sample size). However, none of that really matters, because it didn’t reach statistical significance, meaning, it didn’t reach the threshold for saying it was unlikely to be due to chance. Which makes sense, I don’t think anyone is arguing that praying for patients would make them do worse.

I mentioned it was a preliminary “feasibility” study – well they ended up doing the subsequent “real” study (MANTRA II). The reference for that one is:

Krucoff MW, Crater SW, Gallup D, Blankenship JC, Cuffe M, Guarneri M, Krieger RA, Kshettry VR, Morris K, Oz M, et al. Music, imagery, touch, and prayer as adjuncts to interventional cardiac care: the Monitoring and Actualisation of Noetic Trainings (MANTRA) II randomised study. Lancet. 2005 Jul 16-22;366(9481):211-7. PubMed PMID: 16023511.

This one had 748 patients, an amount estimated to be powered for statistical significance – in other words, enough for statistical methods to reliably suggest whether any difference between groups was “unlikely due to chance” or not. From their discussion section: “In MANTRA II, we studied two noetic strategies in patients undergoing coronary revascularisation: an unmasked bedside combination of music, imagery, and touch, and a double-masked, off-site array of combined congregational prayers. Neither therapy alone or combined showed any measurable treatment effect on the primary composite endpoint of major adverse cardiovascular events at the index hospital, readmission, and 6-month death or readmission.”

At 6 months, there were 11 deaths in the prayer group vs 9 in the no-prayer group… a nonsignificant finding, meaning that there was no “real” difference.

I can’t find any journal named the “Southland Medical Journal,” I’m guessing you meant “Southern.” My best guess is that he’s referring to this famous 1988 paper:

Byrd RC. Positive therapeutic effects of intercessory prayer in a coronary care unit population. South Med J. 1988 Jul;81(7):826-9. PubMed PMID: 3393937.

I hadn’t before read it, but I have to say that it’s probably the worst piece of “academic” writing I’ve ever read, even for a single author 25 years ago. I’m not sure if the author was actually associated with UCSD (reputable), but I would not consider the journal particularly well-known, I don’t know what criteria you used to deem it a “reputable institution.”

The first sentence in the abstract: “The therapeutic effects of intercessory prayer (IP) to the Judeo-Christian God, one of the oldest forms of therapy, has had little attention in the medical literature.” 2 pages later in the discussion: “In reviewing the social and scientific literature  on the efficacy of prayer to the Judeo-Christian God there seems to be no end to articles discussing it…”

The hospital course was graded by his own non-validated scale: “good,

intermediate, or bad.” Here are a few direct quotes from the study that… suggest the author may have had some bias (bolding mine – remember this is supposed to be academic medical literature… I’ve never seen anything like this):

“For the purposes of this study, intercessors were chosen on the following basis. They were “born again” Christians (according to the Gospel of John 3:3) with an active Christian life as manifested by daily devotional prayer and active Christian fellowship with a local church.“

“This may have resulted in smaller differences observed between the two groups. How God acted in this situation is unknown; i.e., were the groups treated by God as a whole or were individual prayers alone answered?“

“I collected the information on each patient in a blinded manner, without knowledge of the spiritual status, condition, or ideas of the entrants during the study.”

“In addition, I thank God for responding to the many prayers made on behalf of the patients.“

Even then, he admits: “Even though for these variables the P values were <.05, they could not be considered statistically significant because of the large number of variables examined.” So he then explains how he rearranged the data to achieve statistical significance. While the endpoints you mentioned may be true (after he manipulated the data), even then only 6 out of 26 outcomes were improved in the “prayer” arm of the trial.

I applaud Utah’s moves to improve work-life balance. More than cardiovascular risk, though, I hope it improves their mental health – and I think the volunteerism has potential to go a long way towards that. While they may have low rates of heart disease, Utah is frequently found to have the highest prescription antidepressant use in the country at about 20% of the population and the fifth highest age-adjusted suicide rate in the country.

I was going to post this as a comment to the blog, but it’s probably more appropriate as an email. The way I look at it is this: I don’t think you really care what science has to say about religion, so I don’t think it really matters to you whether or not science shows prayer to be helpful in healing. I’ll confess that I think it’s intellectually dishonest for you to care only if there are positive results, and claim not to care if no benefit is found. More importantly, I get upset when my family is actively deceived by fraudsters looking to make a buck with sensationalistic articles; your blog post applauding his article and linking to his site contributes (financially and morally) to Dr. Crandall’s misrepresentation of the medical literature.