"If it is a Miracle, any sort of evidence will answer, but if it is a Fact, proof is necessary”
If you were tasked to take an evidence based approach to miracles in medicine, where would you start? Would you search Pubmed, Web of Science, or PsychInfo? Would you start off asking your colleagues and experts in the field? Would you just give up and say that miracles are based on faith, so one cannot explore spiritual beliefs and practices from an evidence-based approach?
In a journey that I started a little over a year ago, I stumbled along many different paths to try to use scientific evidence to answer the question of how one should approach patients and family members who hope for a miracle. Luckily, I had some of the very best minds helping me along, including the likes of Ken Rosenfeld, Erik Fromme, Dan Sulmasy, and Bob Arnold.
I began my journey with trying to answer the question of what constitutes a miracle and whether they actually occur in medicine. You can try to separate these questions, but to answer the latter, you would need to first define the former.
I first stumbled upon Littlewood's law of miracles, which fit perfectly with my representation of the world and meaning of the word miracle. Littlewood defined a miracle as an exceptional event of special significance occurring at a frequency of one in a million. Littlewood estimated that, if an awake human typically experiences one exceptional or unexceptional event per second over the course of the 8 hours they are awake, then in 35 days he/she will have experienced about one million events (both exceptional and unexceptional). Therefore, a miracle using Littlewoods definition would be commonplace, and should be expected to occur on average every 35 days. For an ICU operating 24 hours a day, miracles would be even more common, happening every 12 days.
I was thankfully quickly redirected by my team of mentors, who highlighted the central difference between my (the clinician's) view of a miracle as a very rarely occurring event, and many patients' & families' view of a miracle as something that occurs not by chance but as a function of divine intervention. "Crap", I thought to myself, how do I tackle the divine using evidence based medicine?
Taking the standpoint of the patient and family, rather than the clinician, helped in finding a way to deal with this question. The question for the clinician isn’t really whether miracles happen, but rather what they mean to patients & families and how we can support patients & families with their meaning. So, together, we came up with a different plan, one that attempted to answer the following questions:
- Among the general public, what is the prevalence of the belief in miracles or divine intervention?
- Among patients with advanced illness or their surrogates, what is the meaning of “hoping for a miracle” in the context of medical decision making?
- Among patients with advanced illness or their surrogates, does the belief in miracles or divine intervention influence medical decision making?
- Among patients with advanced illness or their surrogates who hope for miracles, does the support of spiritual needs by medical teams decrease the likelihood of aggressive end-of-life care or improve bereavement outcomes?
- Among patients or surrogates who hope for miracles, is there a communication approach that decreases the likelihood of aggressive end-of-life care or improves bereavement outcomes?
The answers to these questions were not easy to come by, and often, there was a dearth of good literature on the subject. However, from the literature that we did come across, I learned some very important lessons. The most important to me from a clinical standpoint is that all of the evidence points to the fact that belief in miracles is not only common among those we care for, but this belief plays a crucial and under-recognized role in medical decision-making.
You can read more about the answers to these 5 questions in the paper we just published in the Journal of Pain and Symptom Management titled: "Approaching Patients and Family Members Who Hope for a Miracle."
This paper was probably one of the most challenging for me to get my head around, so I'd love to hear your feedback. Specifically, would you have taken a different approach & would you ask different questions than the ones we asked?