Abstract and Introduction

Spirituality & Aging in Modern Society

Increasing longevity in modern society puts the spiritual needs of older adults at the forefront of societal priorities in providing care for the elderly. Nonetheless, Western society continues to struggle with antiaging attitudes, which tend to ignore the talents and creative contributions of older adults, expressed in the lack of opportunities for either vocational retraining and employment, or community service. Additionally, retirement communities catering to older adults tend to place an emphasis on activities rather than the spirituality of creativity.[6] Historically, the elders of society functioned as transmitters of sacred knowledge and rituals. They established anawareness of the culture and roots that are necessary for the health and growth of the community.[6] With the growing populationof older adults, the role of an elder in the society should be expanded, to enrich and give meaning to lives of its aging citizens.

In the US general population, religious participation has always been prominent, with over 90% of Americans believing in God or a higher power, 90% praying, 67–75% praying daily, 69% being members of a church or synagogue, 60% considering religion to be very important in their lives and 82% acknowledging the need for spiritual growth.[6–9] There is also evidence from research that patients want to be seen and treated as whole people, not as disease states.[1,10] Being a whole person implies having physical,emotional, social and spiritual dimensions. Ignoring any of theseaspects can interfere with healing.[9,11] In healthcare systems, many patients want their physicians to integrate religion; over 75% want their physicians to include spiritual issues in their care.[12–14] Yet, frequently, families and healthcare providers of older adults are poorly prepared for integrating spirituality into the consideration of life and healthcare decisions. According to surveyed physicians, lack of time, inadequate training and discomfort in addressing the topics are responsible

for the discrepancy.[15,16] Overcoming these barriers toward properassessment, and understanding and respecting an individual's spirituality can help shape personalized medical care for older adults, and improve health outcomes.

However, research on spirituality struggles to maintain a nonsectarian approach to studying spirituality, owing to the highly heated religious preferences of various authors,[17] which polarize gerontological literature on spirituality, religiosity and aging. Although the concept of spirituality is multifaceted and does not lend itself to an easy definition, further research will depend on the use of stronger and nonambiguous definitions and measures that will unify research efforts and determine success.[5] Atchley addresses this issue explicitly, asserting in his introduction:[17,18]

"I avoid religious language as much as possible because I have found that, although it may be helpful for the ingroup, it often activates a sense of intergroup division and difference."

It seems that finding common grounds in pursuing knowledge about benefits of spirituality is more important for the benefit of thefield and the population at large, rather than emphasizing relatively minor differences among religious practices. Spiritualinterventions can help relieve psychological distress and fear ofdeath, as well as the stresses of caregiving for loved ones with chronic illnesses in later years. As in all other domains of clinical research, spiritual interventions have limits, and must be applied with caution for both technical and ethical reasons. As scientific knowledge of spirituality expands, so does awareness of the need for further research, including the refinement of methodological procedures, expansion to new topics and extension to international cultures and diverse religions.[5]

Psychological & Gerontological Theories of Resurgence of Spirituality with Aging

Psychological and gerontological theories try to explain the increase in spiritual activities in later life from a broad rangeof perspectives. For example, the socioemotional selectivity theory proposes a greater emphasis upon emotion-related goals as individuals become aware of the brevity of life.[19] Jung proposedthat increasing spiritual goals, and pursuits with an increase inintrospection, are a natural part of the maturational process from mid to later life.[20] The disengagement theory assumes societal benefit from older adults' withdrawal from roles and activities that is universal and inevitable prior to death. It leads to the mutually satisfying exchange in the society: the youth begins to expand in the population, while the retiring older adults are released.[21] The Duke Longitudinal Study of Aging found that religious attitudes and satisfaction remain the same with aging, but the correlation with happiness, feelings of usefulness and personal adjustment increase.[22] Contrary to the disengagement theory, the activity theory emphasizes increased activities (e.g., volunteering), and measures success of aging bythe number of active roles.[23,24] Atchley developed the 'continuity theory', which assumes that individuals develop preferences as a part of their personality and, as they grow old,they continue in their spiritual tradition.[25] Atchley also triedto use a nonreligious approach to describe spirituality as 'deep inner silence', 'insight', 'compassion', 'connection with the ground of being', 'transcendence of personal self', 'wonder', 'transformation', and a 'concept that sensitizes us to a region of human experience and tells us generally what to look for in that region'. He also considered the role spiritual beliefs and practices play in coping with the problems of later life, especially with regard to the experience of time, dying and death, before concluding with his own reflections and some implications of his work.[25] A related concept of

gerotranscendence, introduced by Tornstam, defined a transition from a materialistic and rationalistic perspective to a more cosmic and transcendent view of life that accompanies the processof aging.[18,26–30] The Cosmic Transcendence subscale of the Tornstam's Gerotranscendence Scale has proven to be the most consistent, and is related to having a sense of meaning of life and the degree of religious involvement.[31,32]

Spirituality & Successful Aging

The notion that a spiritual perspective becomes increasingly important with aging adds a positive spin to the search for a 'positive death' or a 'spiritual journey'.[33] The concept of successful aging, which emerged from the 1990s McArthur Research Network on Successful Aging, brought about an interest in positive aging. Spirituality and religious participation are highly correlated with positive successful aging, as much as diet, exercise, mental stimulation, self-efficacy and social connectedness, stimulating an interest in the understanding of why spirituality has such positive effects on the quality of lifeand end of life. Crowther et al. proposed that positive spirituality is defined by developing an internalized relationship with the sacred and transcendent world that is not bound by race, ethnicity, economics or class, and promotes the

wellness and welfare of the self and others.[34] This attitude is more positive, and promotes self-enhancing behaviors and beliefs.Rogers claims that the universality of religion is based upon itssocial function during the later years of life, such as helping face inevitable losses and impending death, while also finding and maintaining meaningfulness of life.[35] Older adults who are more religious tend to demonstrate greater wellbeing than those who are not.[36] However, Seifert warns against the sentiment of assuming that spirituality automatically increases with age.[37] Additionally, MacKinlay implicitly addresses this concern when she observes:[

"Successful aging is essentially a wellness model of aging and, as defined, isolates older people with disabilities, physical or mental, outside the model."

In those individuals, the success of their aging should be measured according to spiritual traditions of humankind that respect the role of an elder in the society.[6] In summary, spirituality appears to play an important and adaptive role in aging that seems to lead to a better quality of life and life satisfaction, as well as longevity in the older practitioners.

Definitions of Spirituality: Spirituality versus Religiosity

The definitions of spirituality have been changing over time, andare increasingly considered a construct related to mental and physical health. Despite centuries of debate, there is little consensus on the meanings and definitions of spirituality and religion. Hill and Pargament suggest that spirituality can be understood as a search for the sacred, or a process of self-discovery in relation to the sacred.[39] Many writers emphasize a search for a meaning to life as a central aspect of spirituality.[38,40–42] Traditionally, spirituality was used to describe the deeply religious person, but it has now expanded to include the religious seeker, the seeker of wellbeing and happiness and the completely secular person. The definitions of religion generally include an organized system of beliefs, practices, rituals and

symbols, designed to facilitate closeness to the sacred and transcendent, and to foster religious communities. Spirituality encompasses religion but spreads beyond to promote an understanding of the meaning of life, and an individual's relationship to the transcendent.

Individuals involved in new-age spirituality frequently proclaim that they are spiritual but not religious. In this context, spirituality is the human awareness of a relationship or connection that goes beyond sensory perceptions. This relationship is perceived by each individual, and is an expanded or heightened knowledge beyond or outside of his or her personal being. Spirituality was eloquently defined by Holmes as "a human capacity for relationship with that which 'transcends sense phenomena'".[43] A person perceives it as a heightened or expandedconsciousness that is independent of one's efforts and that deepens one's awareness of self, others and the world.

In the landmark Spiritual Wellbeing Section of the 1971 White House Conference on Aging, the definition of spirituality is centered around people's inner resources, especially their ultimate concern for the basic value around which all other values are focused. The central philosophy of life; whether religious, antireligious or nonreligious, guides a person's conduct to the supernatural and nonmaterial dimensions of human nature.[44] The National Interfaith Coalition on Aging was organized in 1971 and defined spiritual wellbeing as the affirmation of life in a relationship with God, self, community and environment that nurtures and celebrates wholeness.[45] The spiritual permeates and gives meaning to all life. The term 'spiritual wellbeing' indicates wholeness by contrast to fragmentation and isolation.[46] The evidence of spiritual wellbeing includes positive self-concepts, unselfish giving, moral character, beliefs in the all-encompassing God and personaltranscendence, for example.

In a study by Zinnbauer and colleagues, of 346 individuals who were asked to define religiousness and spirituality, religiousness included both the personal beliefs in God and organizational practices, such as church attendance, as well as

higher levels of authoritarianism, orthodoxy, parental religious attendance and self-righteousness.[47,48] Spirituality is most often described in experiential terms, such as faith in God or a higher power, or integrating one's values and beliefs with behavior in daily life. It is associated with mystical experiences and new-age beliefs and practices. Although religiousness and spirituality describe different concepts, they are significantly correlated. Most people consider themselves to be both religious and spiritual. Their self-rated religiousness and spirituality are associated with frequency of prayer, church attendance, religious orthodoxy and an intrinsic religiosity thatuses religion as a guide for everyday decisions.[6] Although 93% identify themselves as spiritual, some rate themselves high on spirituality and low on religion, while others are moderate on both.[6] Most believers approach the sacred through the personal, subjective and experiential path of spirituality, even though they differ on whether they should include organizational or institutional beliefs and practices in their self-identity. It isthe responsibility of mental health professionals and general practitioners to understand what spirituality means to each individual in order to provide complete holistic care of their psychological and spiritual needs.

Spirituality & Physical Health

Empirical research helps bring clarity to the health benefits of spiritual and religious practices. Many large community surveys, such as the Established Populations for Epidemiological Studies of the Elderly, have included items assessing religious and spiritual practices.[54] Despite racial, religious and cultural variations, the main exception is diminished attendance at religious services among the elderly who have problems of health and mobility. Their reduced participation in organizational religiosity, however, is often accompanied by high levels of nonorganizational religiosity: praying, listening to religious radio programs and music, and gaining help from religion to understand their own lives.[55] The differential survival hypothesis suggests that people who are more spiritual and religiously committed have lifestyles that lead to reduced

mortality. They are less likely than others to use tobacco, abusealcohol and drugs, engage in premarital sex or become divorced. They are more likely to belong to supportive social networks, andto experience serenity and peace with themselves, other people and God. Their lower age-specific mortality throughout adulthood could be a significant source of the high average spirituality ineach older generation. A study of over 20,000 US adults estimatesthat religious involvement prolongs life by approxiately 7 years.[56]

Various systematic reviews and meta-analyses have demonstrated that religious involvement correlates with decreased morbidity and mortality.[57–64] In patients after heart surgery, Contrada andcolleagues found stronger religious beliefs were associated with shorter hospital stays and fewer complications.[65] On the other hand, Hodges and authors did not find that spiritual beliefs affected recovery from spinal surgery.[66] Some studies suggest that members of different religions may have different mortality and morbidity, even when adjusting for major biological, behavioral and socioeconomic differences.[67,68] Both religious affiliation and regular attendance at religious services appear to buffer the need for, and length of, hospitalization.[69] Most studies find positive correlations between religious beliefs, behaviors and mental and physical health.[3] For example, various studies have revealed an inverse relationship between religious commitment and hypertension, fewer strokes, less pain from cancerand other illnesses, than similar people with a low religious commitment.[3,70–73] In Comstock's and Partridge's analysis of 91,000 people in Maryland (USA), those who attended church had a lower prevalence of cirrhosis, emphysema, suicide and death from ischemic heart disease. There has been a surge in the popularity of spiritual interventions, such as yoga or meditation, to improve and maintain health.[74–76] In three studies of prayer, large groups were invited to participate in a group prayer for patients with acute cardiovascular problems. Those who were prayed for did overall better than the control group in terms of the number of cardiovascular arrests, congestive heart failure, pneumonia, intubation and antibiotic use.[77–79]

Studies have compared people with high and low religiosity on healthier and less risky lifestyles, which might account for the association with better health. Religion may provide structure teaching, positive role models and support to individuals, which would prevent risky behaviors. Compared with the general population, Mormons and Seventh Day Adventists have been found tohave lower incidences and mortality rates from cancers that can be linked to tobacco and alcohol use.[80,81] However, other studieshave not supported this relationship.[82,83]

Although many patients consider religion and spirituality to be important in their healthcare, it is rarely used in the healing process. There has been a surge in the popularity of spiritual activities, such as yoga or meditation, to improve and maintain health.[74,75] Religious beliefs may help patients cope and providethem with a meaning to their diseases.[84–86] In addition, along with encouraging healthy lifestyles, religious groups may promoteaccess to better healthcare and sponsor preventive programs (e.g., blood pressure and diabetes screening, soup kitchens and food drives).[87,88]

Although most studies have shown the positive effects of religionand spirituality on health, a few systematic studies have shown that religious involvement and spirituality are associated with negative physical and mental health outcomes. Religious beliefs can affect a person's health by encouraging avoidance or discontinuation of traditional treatments, or leading to a delay or failure to seek timely medical care, such as transfusions or contraception, leading to higher mortality.[89] In addition, religions can stigmatize those with certain diseases, and preventthose from seeking proper medical care.[90,91] Religious practices,such as exorcism, can be dangerous and lead to death.[92] Finally,fanatic religious beliefs can affect physical and mental health adversely.[93]

Spirituality & Mental Health: Coping & Adaptation

The impact of religion and spirituality on mental health has beenstudied more extensively than the impact on physical health. Muchof the research on spirituality and aging has looked at the relationship between spiritual or religious coping and health. Musick and colleagues identified approximately 370 studies dealing with the association between religion and physical/mentalhealth.[94] A large number of writers would like a greater understanding of spirituality and meaning in old age,[95] or religious coping and life outcomes.[37] Spiritual health is closely related to mental health and psychological coping.[96,97] Providers of clinical services have a responsibility to take the 'whole' person into their work with clients[98] and integrate spiritual issues into the psychological or medical care of older adults.[2,69]

There is abundant evidence that spirituality and religious participation are associated with positive mental health outcomes. Koenig and coleagues reviewed 325 studies, and found a significant relationship between religious involvement and bettermental health, physical health and the use of health services.[1] Williams concluded that religious attendance buffered the effectsof stress on mental health.[99] In Coward's study of 107 women

with advanced breast cancer, spirituality appeared to improve emotional wellbeing.[100] Studies have demonstrated religiosity to be related to wellbeing in white Americans, Mexican–Americans,[101]

African–Americans[102] and in different age groups.[103] Intrinsically religious people internalize their faith, and have higher self-esteem, better personality functioning, less paranoiaand lower rates of depression or anxiety, while extrinsically religious people use religion to obtain status, security, sociability or health.[73,104] Findings are mixed about whether religion increases or decreases anxiety.[52] Religious coping is inversely related to depressive symptom severity in the veterans.[105,106] However, only two-thirds of the US population consider religion to be an important influence in their life.[104]

Most studies find that higher religiousness and spirituality are associated with lower levels of death, anxiety or alcoholism, with better marriages, reduced loneliness lesser distress among dementia caregivers, and better mental health.[3] Data drawn from the first and second results of the Duke Established Populations for Epidemiologic Studies of the Elderly demonstrated that religious attendance may offer mental stimulation, which helps tomaintain cognitive functioning in later life, particularly among older depressed women.[107] A few studies have addressed differences between religions. One study in older women in Hong Kong showed that Catholics and Buddhists enjoyed a better mental health status than Protestants.[108]

A number of studies examine the association of religion with depression. Prospective cohort studies have shown religious activity to be associated with remission of depression in Protestants, Catholic Netherlanders[109] and in ill older adults.[87] In total, 24 studies in the research literature have found that religiously involved people had fewer depressive symptoms and less depression[93] or less anxiety.[54] Approxiately 80% of existing research has also suggested an inverse correlation between religiosity and suicide.[110–112] Suicide may be less acceptable to people with high religious devotion and religious beliefs. Several randomized controlled trials demonstrated the benefits of religion-based cognitive therapy on Christian

patients with clinical depression.[113] Three randomized controlledtrials suggest that Islamic-based religious psychotherapy accelerated recovery from anxiety and depression in Muslim Malays, but did not control for the use of antidepressants and benzodiazepines.[114–116] Religious commitment also has been found to moderate the relationship between functional disability and depression.[117]

Religious and spiritual themes can be present in the context of mental illness, such as schizophrenia or bipolar disorder. On another note, highly stressful life events can transform normative religious beliefs into excessive preoccupations that involve delusional guilt. Richards and Bergin advise to restrict spiritual interventions and explorations to less-disturbed patients; that is, outpatients without psychotic or severe mood disorders.[11,104]

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Spiritual Development & Aging

Spirituality serves several purposes in different stages of life,which is similar to the concept of different needs and conflicts associated with different ages, as stated in Erikson's eight stages of human development (1963).[49] In addition, Fowler recognized six stages of faith, and also recognized the fact thatindividual development may stop at any stage:[50,51]

Intuitive–projective faith (ages 2–7 years): when child becomes aware of God;

Mythic–literal faith (ages 7–12 years): when family specified perspectives and meanings of morals and God are internalized;

Synthetic–conventional faith (adolescence onward): when faith is accepted without critical evaluation;

Individuative–reflective faith: when an individuals own belief is critically examined and reconstructed;

Conjunctive faith (midlife and beyond): when disillusionmentwith that belief system sets in, and one is caught between it and openness to other religious traditions;

Universalizing faith (late life): brings oneness with the power of being or divinity, willingness to promote justice in the world and fellowship with others, regardless of theirfaith stage or religious tradition.

Koenig questioned Fowler's approach of applying cognitive stages of faith development to older adults with low levels of educationor physical/cognitive dysfunction.[52] Regardless of differences in the theories of faith development, most emphasize faith development in late life after completion of all developmental cognitive stages. Spirituality is a lifelong developmental task, lasting until death.[53]

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Spirituality & the Attitudes Toward Death & Dying

The continuing advances of medical technology have altered attitudes toward dying. Dying is no longer a part of human daily consciousness or an accepted final event of life. Kübler-Ross insisted that the dying stage in our life can be experienced as the most profound event of our life experience. Dying begins whenthe facts of life are finally recognized, communicated and accepted.[118]

Most of the research on dying and death is recent, and has falleninto two categories: probing emotions or attitudes surrounding

death, and investigations exploring the experience of dying itself. Most elderly people recognize that their own death is close. Older people tend to think about dying and death more thanany other age group.[119] Most researchers consider the fear of dying as the most prevalent emotion. The findings about the relationship of age and fear of dying are mixed.[120,121] Other emotions linked to death and dying are hope and the continuity ofhope,[122] the feeling of loss (e.g., of control, competence, independence, people or dreams for the future),[123] loneliness,[124]

dignity/integrity,[125] forgiveness[126] and love.[127] As a society, we shy away from death and the idea of termination. In recent years, research has led people toward greater awareness and an increase of interest in the dying process and death. Spiritualityand storytelling can be used as resources in aging successfully and in dying given the constraints of the modern-day western culture.[128]

Developing interventions will raise awareness of the dying process and, ultimately, result in a more peaceful experience. These interventions will likely improve the experience of death and dying for the patient and their families in various medical settings, such as palliative care, hospice, long-term care and primary care settings.[129,130]

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Spiritual Care by Healthcare Providers

Despite the controversy, the role of religion in healthcare is growing. The guidelines of the Joint Commission on Accreditation of Healthcare Organizations require hospitals to meet the spiritual needs of patients.[131] The 'Diagnostic and Statistical Manual of Mental Disorders – Fourth Edition' (DSM) recognizes religion and spirituality as relevant sources of either emotionaldistress or support.[132,133] The recently published edition of the DSM-V Research Agenda specifically addressed religious and spiritual issues in psychiatric diagnosis.[134] The medical literature on religion and spirituality has increased by 600% from 1993 to 2002.[135] Some have recommended that physicians take into account the religious and spiritual histories of their patient to better understand their backgrounds and beliefs.[136,137]

There has also been a greater emphasis on integrating various religious resources and professionals into patient care, especially when the patient is approaching the end of their life.[137] Some effort is made to train healthcare providers to better understand spiritual practices, listen to a patient's religious concerns and perform clergy-like duties when religious professionals are not available.[138]

Assessment of Spirituality in Clinical Practice

Acknowledging the spiritual lives of patients may involve asking about their spirituality when recording their history during the clinical interview, which may not be appropriate for every patient. Some practitioners suggest four simple questions that might be asked of seriously ill patients:[11]

Is faith (religion, spirituality) important to you in this illness?

Has faith been important to you at other times in your life? Do you have someone to talk to about religious matters? Would you like to discuss religious matters with someone?

In addition, open-ended questions allow patients to tell healthcare providers about how they view relationships, the meaning of their illness and what type of coping mechanisms have

helped them in the past. Patient responses to these questions canyield information about spiritual concerns and practices that mayhelp healthcare providers better understand their patients' worldly perspectives. This understanding can help practitioners determine whether patients' religious and spiritual beliefs, as well as community involvement, can be a useful resource to assistwith their coping and healing process.[11]

Obtaining a spiritual history from the patient can be aided by using spiritual history tools, including FICA (Faith, belief, meaning; Importance/Influence in healthcare decision-making; Community; Address/Action in treatment plan),[139] HOPE (Sources ofHope; Organized religion; Personal spirituality; Effect on medical care and end-of-life issues),[140] and SPIRIT (Spiritual beliefs; Personal beliefs; Integration with spiritual community; Rituals; Implications for care and Terminal care).[141,142]

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Measuring Spirituality in Clinical Practice & Research

Measuring spirituality in clinical practice and research has beena challenge because of the complexity of contributing elements and definitions. There is no widely accepted measure of spirituality.[143] Components such as spiritual wellness and spiritual maturity received more attention, because scientific

research depends upon measurement, while human services require assessments.[144] Hill and Hood reviewed 125 measures of religion and spirituality from 17 categories (e.g., beliefs, attitudes, religious orientation, faith development, fundamentalism, attitudes toward death, congregational involvement and satisfaction).[145] Others have identified similar dimensions of religion and spirituality.[146] Measurements of religion and spirituality rely almost exclusively on paper-and-pencil self-report measures, with the limitations of subjective reporting. Accurate assessments can extend knowledge about spiritual wellness, help to diagnose spiritual ailments and indicate the spiritual care needed to restore spiritual health. Instruments used to measure spirituality tend to emphasize questions assessing positive character traits or mental health (e.g., optimism, forgiveness, gratitude, meaning and purpose in life, peacefulness, harmony and general wellbeing).[147]

Table 1 describes more popular instruments and other less-well-known instruments proposed for future research. These instrumentswere selected to demonstrate the breadth of the various aspects of spirituality that can contribute to the health outcomes in theelderly. The Spiritual Wellbeing is a popular and excellent way to assess spiritual and religious commitment in a person's life.[148] The Spiritual Perspective Scale similarly assesses the importance of spirituality in a person's life, but does not subdivide the religious and spiritual domains as the former scaledoes.[149,150] The Spiritual Perspective Scale was used in a terminal population. In order to use the Spiritual Wellbeing, it would need to be tested in this same population. The Multidimensional Measurement of Religiousness/Spirituality – 59 items has been used in religion/spirituality research, and demonstrated good reliability and validity in assessing three primary factors (meaning, spirituality and religious practices), and two secondary factors (guilt vs God's grace and loving/forgiving God). Stewart and Koeske and Underwood and Teresi reported on the reliability and validity of the Daily Spiritual Experience Scale, with internal consistency greater than 0.9.[151,152]

The following three scales are of interest for future research because of the importance of the domains they address for the aging population coping with death and dying. The Death Attitude Profile analyzes the fear of death.[153] The Death Transcendence Scale looks at how people transcend death and can be used by the healthcare professional in guiding patients through their last days.[154,155] The Herth Hope Index is an excellent scale used to assess the patient's hopefulness.[155] Knowing that a person is hopeful guides the provider in determining ways to sustain that hope. If a person lacks hope, the providers would need to determine what aspects of their life could be drawn upon in orderto ignite hope within the dying patient. Given the correlation oflow scores on the Herth Hope Index with depression and low self-esteem, the clinician should assess the patient for depression and self-esteem. In addition, we would recommend adding specific questions regarding how well the patient's spiritual needs are being met.

For future research, new instruments will be needed to assess thespiritual needs in the dying population, which incorporates the concepts of death transcendence, spiritual and religious wellbeing, and hopefulness, as well as to assess how well those needs are being met. We need to use these instruments to test whether specific interventions can improve their spiritual wellbeing, increase their hopefulness and enhance their meaning in life (Table 1).

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Training in Spirituality for Healthcare Professionals

A growing number of medical schools are offering courses in spirituality in medicine.[156] Some programs focus on spirituality and medicine, while other courses included additional components on cultural competency and end-of-life care. Most curricula used several educational methods, such as lectures, small group discussions, standardized patient interviews and readings. Spirituality may be taught in several venues, including courses on holistic medicine and complementary and alternative medicine. Fortin and Barnett indicated that in the recent survey of complementary and alternative medicine course directors at 53 medical schools, 64% included teaching about spirituality, faith and prayer.[156] Puchalski recommended integration of the medical school curricula into a step-wise integration from basic to more sophisticated and specialty relevant material, extending into residency years with interdisciplinary courses that include nursing, social work, allied health and clinical pastoral education programs, with faculty representation from theology, chaplaincy and humanities.[142] Spirituality can be taught in the context of compassionate communication skills, especially in the end-of-life care in chronic disease care model. Some of the courses where spirituality can be integrated, include courses on ethics or medical humanities, longitudinal courses in doctor–patient and society relationships or practice of medicine. Use ofstandardized patient spirituality case scenarios for teaching, evaluation and testing the students and residents can also be recommended.[142] Evaluation of the programs has been challenging, as schools have different curricula. Most schools evaluate program effectiveness with standard surveys assessing course satisfaction and changes in knowledge skills and attitudes.

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Research on Spirituality

The challenges that research on spirituality and religion face include logistical and funding limitations, but also the ambiguity of defining and measuring spirituality and religiosity.

There are very few well-designed large-scale studies. Many publications are purely anecdotes or editorials, which can stimulate discussion but cannot establish causality or scientifically justify the use of specific interventions.[157] The majority of existing studies are correlational, which may be plagued by spurious findings. For example, in a systematic reviewof studies from 1996 to 1999, Townsend and colleagues counted nine randomized controlled trials.[158] Hopefully, with increasing interest in spirituality and mind, the number and sophistication of scientific studies should continue to improve.[158]

Some of the inherent challenges of defining and measuring spirituality lie in separating religiosity and spirituality,[159,160] which is particularly important in studying participants who consider themselves spiritual but not religious. Subjects maybe unwilling to alter their religious beliefs or practices for a study with a design that uses a particular spiritual practice. Monitoring of practice adherence or correct performance of a subject may become a problem. In these cases, a subject inadvertently may be noncompliant.

The use of accurate and valid measures of religiosity and spirituality is very important, with different rating scales identifying subjective and objective measures of either. The use of daily diaries can be helpful to track compliance with daily practices. When considering the direct effects of religious or spiritual activities on one's health, it is important to considersecondary effects, such as an increase in social support, social activities leading to improved chances of finding a life partner,or chances for better healthcare. Establishing the direction of

causality can be challenging. For example, health status can influence whether a person can participate in a religious activity. Practices and doctrines can vary among different religions and denominations. Local environments can influence thestatus of religious movement and add stress if a particular religion is an object of persecution. It is not entirely clear what the proper duration of the spiritual intervention should be,such as prayer, yoga or meditation, all of which may have immediate or delayed effects on physiological measures, such as blood pressure or markers of inflammation. Multidisciplinary research, although necessary, can be challenging because of the differences in definitions and motivations. Some of the scientific approach limitations include failure to control for confounding variables and other covariates, as well as to controlfor multiple comparisons using multiple statistical procedures, which can lead to the biased estimation of an association.[161]

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Spiritual Interventions

Religious or spiritual activities can be practiced to help treat or prevent illnesses. Richards and Bergin differentiate between religious and spiritual interventions on the basis of structure.[104] Religious interventions are more structured, denominational, external, cognitive, ritualistic and public, whereas spiritual interventions are more crosscultural, affective, transcendent andexperiential. Interventions should be agreed with the patient, and tailored to their worldly perspectives to help them during anillness or crisis.[103] Spiritual interventions are contraindicatedin cases of psychotic illnesses when dealing with poor 'ego boundaries', or when a patient does not want to participate. Not

all of the cited studies that follow in this article were performed strictly in the elderly, but they may inform future research on spirituality and aging.

Prayer & Religious Rituals

Prayer is a powerful form of coping that helps people physically and mentally. Nearly 60% of Americans report praying daily.[162] Prayer is a communication or conversation with divine powers or a'higher self.' Prayer is practiced by all Western theistic religions and several of the Eastern traditions (e.g., Hinduism, Sikkhism, Buddhism and Taoism). Group prayer is associated with agreater wellbeing and happiness, while solitary prayer is associated with depression and loneliness.[163] However, scientificvalidation of the efficacy of prayer, in terms of health outcomes, remains in its infancy when dealing with positive and negative biases.[164] A number of studies report negative findings on the therapeutic effects of intercessory prayer, and illustratethe need for nonbiased experimental designs. Critics of prayer research have proposed that the benefits of prayer may be the results of a placebo effect.[164] Open dialog and refining researchmethodology in studies of the health benefit of prayer can help discern potential health effects.

Worship and religious rituals are encouraged by most religions. Benson suggests that potentially therapeutic elements of worship include music, asthetic surroundings, rituals, prayer and contemplation and opportunities to socialize with others.[165] Bibliotherapy involves the use of literature to help gain insightinto feelings and behaviors, and to assist with positive coping. All major world religions have a text that their followers view as holy, and use as a source of comfort, wisdom and guidance.[166] All major theistic world religions teach that people should accept and forgive those who have harmed them and seek forgiveness from those whom they have harmed.[104] Spiritual reading and practicing forgiveness and repentance are significantparts of any 12-step program.[11,167–169] Steps 4 and 5 of Alcoholic Anonymous involve public 'confessions', and recounting of one's wrongdoing. In medical settings, forgiveness and repentance are within the purview of a pastoral counselor and clergyperson.[170]

Both prayer and bibliotherapy with sacred writings must be consistent with patients' needs and requests.

Meditation

Meditation, essentially, is a physiological state of reduced metabolic activity that elicits physical and mental relaxation, and is reported to enhance psychological balance and emotional stability.[152–159] Meditation produces the sense of calm, limited thought and attention. Meditation is widely used as an alternative therapy for physical ailments.[171] Meditation involveseither the narrowing or focusing of the attention on internal events, such as breathing, an object, one point in space or a mantra (in Buddhist or yoga practices), or expanding the attention nonjudgmentally on moment-to-moment experiences, and observing thoughts and feelings from a meta-cognitive awareness state (Mindful Meditation, Vipassana and Zen Buddhist practices).[172] Many physicians now routinely recommend meditation or yoga techniques to their patients, and include them as a part of integrated health programs, although some forms of Eastern mediation may be viewed in an unfavorable way by Christian patients.[173] While evidence is not yet definitive, preliminary studies suggest health benefits of meditation for improved reaction time, creativity and comprehension.[174,175]

Ethical considerations should be taken into account when practicing or recommending spiritual interventions by healthcare professionals, to avoid promoting self-interest or imposing personal beliefs on patients via linking religious practices to better health outcomes;[11] acknowledging limitations of current research into the effects of spirituality on health and, most importantly, respecting patients boundaries and beliefs by obtaining their informed consent to share their spiritual historyand choosing spiritual interventions should be recognized.[11]

Mindfulness Meditation

The effort to develop a cohesive understanding of mindfulness is useful for both clinicians and researchers, but it has proven to be difficult to define.[176,177] Kabat-Zinn gave definitions of

mindfulness as a conscious discipline of paying attention to the present moment in a particular way and in a nonjudgmental state.[178,179] Three key elements of the definition include intentionality, present-centeredness and absence of judgment; or,as Shapiro described, the processes of intention, attention and attitude engaged simultaneously in the process of mindfulness.[180]

The Mindfulness-based Stress Reduction Program (MBSR) has been used in people with physical or psychological symptoms to alleviate the 'stress' that tends to be inherently holistic and nonpathologizing.[181] The structure of the MBSR program involves alimited number of sessions over the course of 8 weeks. Scheduled class time each week is divided between a formal meditation practice, a small- and large-group discussion, and inquiry with individuals into their present-moment experiences. Formal MBSR practices may include mindfulness body scans (a sitting meditation while focusing on controlled breathing), mindfulness Hatha yoga (a sitting meditation with expanded awareness of several objects of attention), a walking meditation and an eatingmeditation. The participant outcomes include discovering embodiment (interoception and proprioception), experiencing new possibilities or new ways of perceiving, observing experience, moving toward acceptance and a growing compassion for self and others. A number of studies and meta-analyses document the usefulness of the MBSR approach for mental health and psychosocial adjustment of cancer patients.[181] The studies indicated that the MBSR approach resulted in decreasing anxiety and distress in cancer patients, and an overall improvement in immunity,[182,183] chronic pain,[184] health-related quality of life in the community-dwelling and nursing-home populations of older adults.[185,186]

Yoga

Practitioners of yoga, the ancient Indian healthcare practice, use breathing exercises, posture, stretch and meditation to balance the body's energy centers. Mindful physical exercise is aspecial kind of physical exercise with an additional element thatfocuses on one's state of mind. A physical exercise is consideredmindful if it posses the following:[187]

A meditative/contemplative component that is noncompetitive and nonjudgmental;

Proprioceptive awareness that involves low-to-moderate levels of muscular activity with mental focus on muscular movement;

Breath centering; Focus on anatomic alignment, such as spine, trunk, pelvis or

proper physical form; Concerns energy centric as an awareness of an individuals'

flow of intrinsic energy or vital life force, for example.

With the aforementioned framework, yoga and qigong are two major streams of mindfulness physical exercise based on the literature.Yoga is used in combination with other treatments for depression,anxiety and stress-related disorders.

There are 22 types of yoga practices, and several modifications of yoga. The most popular in the USA is Hatha yoga, a branch of yoga that requires a vast repertoire of physical postures during sitting, standing or lying on the floor, along with specific breathing patterns. Similar to yoga, the breathing style of qigong is slow and deep in order to achieve body relaxation, clearing of the mind and maintenance of health. Combining all of the mentioned components, mindful physical exercise has been shown to provide an immediate source of relaxation and mental quiescence.[188] Scientific evidence has shown that medical conditions, such as hypertension, cardiovascular disease, insulinresistance, depression and anxiety disorders respond favorably tomindful physical exercises.[189]

Despite a growing body of evidence to show the effects of mindfulphysical exercises, such as qigong, tai chi and yoga, on depression,[189–197] there is a dearth of reviews that examined mindful physical exercise regarding its effects on alleviating depression,[198,199] and even fewer on memory enhancement. A recently released review on complementary and alternative treatments for older adults shows that mind–body interventions were effective on treating depression, anxiety and insomnia in ten out of 12 studies reviewed.[192] In a recent review of Tai Chi and Qigong interventions, in 36 research reports with a total of

3799 participants, significant improvement in physical function and reduce blood pressure, fall risk, and depression and anxiety were reported.[200] An integrated approach of yoga therapy in menopausal women improved cognitive functions, such as remote memory, mental balance, attention and concentration, delayed and immediate recall, and verbal retention and recognition tests.[201] As the 'baby-boomers' grow older, mind–body practices will be more prevalent among older adults, and will require research validation in the elderly.

Neurobiological Mechanisms of Spiritual Interventions

Research into neurobiological mechanisms of spiritual interventions is still limited by a small number of interventionsand small sample sizes. Recent studies using clinical tools and functional neuroimaging have contributed to the growing knowledgeof the biology of meditative practices. Most of the studies have been performed in younger adults or in mixed-age groups, and onlynoted age effect on the outcomes. However, the studies cited in the following paragraphs may guide the development of neurobiological research in older adults to address the effect onaging processes.

Physiological Studies of Meditation

Studies of the meditative state, comparing long-term to short-term meditators, report decreased sympathetic nervous activity, which is important for fight-or-flight reactions, and increased parasympathetic activity, which is important for relaxation and rest.[202–206] Several studies demonstrated predominant parasympathetic activity during meditation, associated with decreased heart rate and blood pressure, decreased respiratory rate and decreased oxygen metabolism.[203,207,208] However, a recent study of two separate meditative techniques suggested a mutual activation of parasympathetic and sympathetic systems by demonstrating an increase in heart rate variability during meditation.[209] Several studies of meditation have observed increases in blood plasma levels of melatonin[210–214] and serotonin,[210,215,216] and chronic increases in long-term meditators compared with controls, or acute increases directly after

meditation. The physiological effects of meditation noted can be beneficial for the management of age-related illnesses, such as heart disease.

Neuroimaging Studies

Functional neuroimaging studies have been able to corroborate these subjective experiences by demonstrating the upregulation inbrain regions of internalized attention and emotion processing with meditation. In a recent systematic review of neurobiologicaland clinical features of mindfulness meditation, Chiesa and Serretti reviewed the current evidence on the neurobiological changes and clinical benefits related to mindfulness meditation practice in psychiatric disorders, in physical illnesses and in healthy subjects.[217] From a clinical viewpoint, MBSR has shown efficacy for many psychiatric and physical conditions, and also for healthy subjects.[217]

Most modern functional imaging studies have been conducted in very small subject numbers, younger populations and without the use of control conditions.[218] Nevertheless, the findings seem to support the evidence that meditation leads to increased activation in frontal and subcortical brain regions, which are important for sustained attention and emotion regulation.[214] Hereby, the most consistent findings across meditation imaging studies are the functional upregulation of brain regions that areknown to mediate attention control.[214] Meditation practices that focus on concentration of an object or mantra seem to elicit the activation of fronto–parietal networks of internalized attention;[219–224] while meditation techniques that focus on breathing may elicit additional activation of paralimbic regions of insula and anterior cingulated,[225] meditation techniques that focus on emotion may elicit fronto–limbic activation.[226] In the recent study of 8-week Kirtan Kriya meditation using single-proton emission tomography, Newberg and colleagues reported significant improvement in cognition in subjects with mild cognitive impairment and in normal older adults, as well as increases in cerebral blood flow in the prefrontal, superior frontal and superior parietal cortices.[222] Future studies will be needed to

disentangle the brain activation patterns related to different meditation traditions.

Further evidence supports the hypothesis that meditation experiences are related to meditation-elicited changes in neurochemicals that are released by limbic brain regions and modulate mood. A functional imaging study using PET compared rest(listening to speech) to active meditation (meditation under verbal instruction) during Yoga Nidra meditation.[227] They found decreased binding of a radioactive tracer that competes with endogenous dopamine in the ventral striatum. This corresponds to an approximate 65% increase in dopamine release in limbic brain regions. All of the physiological effects reported in the neurobiological studies of spiritual intervention point to the potential benefit in improving the health of aging populations. Despite modest progress to date, future research should elucidatethe intricate neurobiological mechanisms underlying meditative practices in aging populations.

Conclusion

Interest in spirituality and aging has increased recently. There are multiple barriers to the proper assessment of spirituality (e.g., the lack of professional training for healthcare professionals, shortage of time, and discomfort in patients and healthcare providers in discussing spiritual issues and needs) inclinical practice and research. Overcoming these barriers via improved training for healthcare professionals can improve healthcare and outcomes in older adults. Improvement of research tools and assessment methods, as well as the development of spiritual interventions, can offer more choices of healthcare to the individuals and their families that are consistent with theirbelief systems. An improved understanding and respect for individual spiritual practices can help shape personalized medical care for older adults, and improve health outcomes.

Future Perspective

The public health significance of spirituality and positive agingis rapidly growing, with an increasing elderly population. The

cost of care for the victims of mental and physical illnesses will increase exponentially in the next several decades. It is important to understand the interaction between spirituality, andphysical and mental health in older adults. Learning to use and enhance spirituality may help improve health outcomes and disability, while enhancing the healing process. Another opportunity to understand the phenomenon lies in the practice of employing spiritual beliefs in promoting and coping with death and dying, especially in the palliative and long-term healthcare settings and hospices.

Training of healthcare professionals in assessing and integratingspirituality into healthcare should be a priority for interdisciplinary training programs via the development of a comprehensive curriculum for medical schools, schools of nursing and social work, allied health and clinical pastoral programs.

Future spiritual interventions that aim to enhance coping and reduce stress in various populations must consider spiritual diversity, and develop targeted programs that offer choices of healthcare based on individual spiritual beliefs, thus creating abasis for personalized healthcare. Future research should test culturally appropriate interventions tailored to the needs of different populations, which combine methods demonstrated to be effective in reducing stress and improving wellbeing and coping. In addition, future studies of the neurobiology of spiritual interventions and individualized spiritual treatment should include neuroimaging, an assessment of individual genetic, psychosocial and biological vulnerability factors that can lead to the development of more effective preventive interventions fordepression and anxiety, and stress reduction in older adults.

A Human Approach to World Peace

When we rise in the morning and listen to the radio or read the newspaper, we are confronted with the same sad news: violence, crime, wars, and disasters. I cannot recall a single day without

a report of something terrible happening somewhere. Even in thesemodern times it is clear that one's precious life is not safe. Noformer generation has had to experience so much bad news as we face today; this constant awareness of fear and tension should make any sensitive and compassionate person question seriously the progress of our modern world. It is ironic that the more serious problems emanate from the moreindustrially advanced societies. Science and technology have worked wonders in many fields, but the basic human problems remain. There is unprecedented literacy, yet this universal education does not seem to have fostered goodness, but only mental restlessness and discontent instead. There is no doubt about the increase in our material progress and technology, but somehow this is not sufficient as we have not yet succeeded in bringing about peace and happiness or in overcoming suffering. We can only conclude that there must be something seriously wrongwith our progress and development, and if we do not check it in time there could be disastrous consequences for the future of humanity. I am not at all against science and technology - they have contributed immensely to the overall experience of humankind; to our material comfort and well-being and to our greater understanding of the world we live in. But if we give toomuch emphasis to science and technology we are in danger of losing touch with those aspects of human knowledge and understanding that aspire towards honesty and altruism. Science and technology, though capable of creating immeasurable material comfort, cannot replace the age-old spiritual and humanitarian values that have largely shaped world civilization, in all its national forms, as we know it today. No one can deny the unprecedented material benefit of science and technology, butour basic human problems remain; we are still faced with the same, if not more, suffering, fear, and tension. Thus it is only logical to try to strike a balance between material developments on the one hand and the development of spiritual, human values onthe other. In order to bring about this great adjustment, we needto revive our humanitarian values.

 I am sure that many people share my concern about the present worldwide moral crisis and will join in my appeal to all humanitarians and religious practitioners who also share this concern to help make our societies more compassionate, just, and equitable. I do not speak as a Buddhist or even as a Tibetan. Nordo I speak as an expert on international politics (though I unavoidably comment on these matters). Rather, I speak simply as a human being, as an upholder of the humanitarian values that arethe bedrock not only of Mahayana Buddhism but of all the great world religions. From this perspective I share with you my personal outlook - that:

1. Universal humanitarianism is essential to solve global problems;2. Compassion is the pillar of world peace;3. All world religions are already for world peace in this way, as

are all humanitarians of whatever ideology;4. Each individual has a universal responsibility to shape

institutions to serve human needs.

Solving Human Problems through Transforming Human Attitudes

Of the many problems we face today, some are natural calamities and must be accepted and faced with equanimity. Others, however, are of our own making, created by misunderstanding, and can be corrected. One such type arises from the conflict of ideologies, political or religious, when people fight each other for petty ends, losing sight of the basic humanity that binds us all together as a single human family. We must remember that the different religions, ideologies, and political systems of the world are meant for human beings to achieve happiness. We must not lose sight of this fundamental goal and at no time should we place means above ends; the supremacy of humanity over matter andideology must always be maintained. By far the greatest single danger facing humankind - in fact, allliving beings on our planet - is the threat of nuclear destruction. I need not elaborate on this danger, but I would like to appeal to all the leaders of the nuclear powers who literally hold the future of the world in their hands, to the

scientists and technicians who continue to create these awesome weapons of destruction, and to all the people at large who are ina position to influence their leaders: I appeal to them to exercise their sanity and begin to work at dismantling and destroying all nuclear weapons. We know that in the event of a nuclear war there will be no victors because there will be no survivors! Is it not frightening just to contemplate such inhumanand heartless destruction? And, is it not logical that we should remove the cause for our own destruction when we know the cause and have both the time and the means to do so? Often we cannot overcome our problems because we either do not know the cause or,if we understand it, do not have the means to remove it. This is not the case with the nuclear threat. Whether they belong to more evolved species like humans or to simpler ones such as animals, all beings primarily seek peace, comfort, and security. Life is as dear to the mute animal as it is to any human being; even the simplest insect strives for protection from dangers that threaten its life. Just as each one of us wants to live and does not wish to die, so it is with all other creatures in the universe, though their power to effect this is a different matter. Broadly speaking there are two types of happiness and suffering, mental and physical, and of the two, I believe that mental suffering and happiness are the more acute. Hence, I stress the training of the mind to endure suffering and attain a more lasting state of happiness. However, I also have a more general and concrete idea of happiness: a combination of inner peace, economic development, and, above all, world peace. To achieve such goals I feel it is necessary to develop a sense of universalresponsibility, a deep concern for all irrespective of creed, colour, sex, or nationality. The premise behind this idea of universal responsibility is the simple fact that, in general terms, all others' desires are the same as mine. Every being wants happiness and does not want suffering. If we, as intelligent human beings, do not accept thisfact, there will be more and more suffering on this planet. If we

adopt a self-centred approach to life and constantly try to use others for our own self-interest, we may gain temporary benefits,but in the long run we will not succeed in achieving even personal happiness, and world peace will be completely out of thequestion. In their quest for happiness, humans have used different methods,which all too often have been cruel and repellent. Behaving in ways utterly unbecoming to their status as humans, they inflict suffering upon fellow humans and other living beings for their own selfish gains. In the end, such shortsighted actions bring suffering to oneself as well as to others. To be born a human being is a rare event in itself, and it is wise to use this opportunity as effectively and skillfully as possible. We must have the proper perspective that of the universal life process, so that the happiness or glory of one person or group is not sought at the expense of others. All this calls for a new approach to global problems. The world is becoming smaller and smaller - and more and more interdependent - as a result of rapid technological advances and international trade as well as increasing trans-national relations. We now depend very much on each other. In ancient times problems were mostly family-size, and they were naturally tackled at the family level, but the situation has changed. Todaywe are so interdependent, so closely interconnected with each other, that without a sense of universal responsibility, a feeling of universal brotherhood and sisterhood, and an understanding and belief that we really are part of one big humanfamily, we cannot hope to overcome the dangers to our very existence - let alone bring about peace and happiness. One nation's problems can no longer be satisfactorily solved by itself alone; too much depends on the interest, attitude, and cooperation of other nations. A universal humanitarian approach to world problems seems the only sound basis for world peace. What does this mean? We begin from the recognition mentioned previously that all beings cherish happiness and do not want suffering. It then becomes both morally wrong and pragmatically

unwise to pursue only one's own happiness oblivious to the feelings and aspirations of all others who surround us as membersof the same human family. The wiser course is to think of others also when pursuing our own happiness. This will lead to what I call 'wise self-interest', which hopefully will transform itself into 'compromised self-interest', or better still, 'mutual interest'. Although the increasing interdependence among nations might be expected to generate more sympathetic cooperation, it is difficult to achieve a spirit of genuine cooperation as long as people remain indifferent to the feelings and happiness of others. When people are motivated mostly by greed and jealousy, it is not possible for them to live in harmony. A spiritual approach may not solve all the political problems that have been caused by the existing self-centered approach, but in the long run it will overcome the very basis of the problems that we face today. On the other hand, if humankind continues to approach its problems considering only temporary expediency, future generations will have to face tremendous difficulties. The globalpopulation is increasing, and our resources are being rapidly depleted. Look at the trees, for example. No one knows exactly what adverse effects massive deforestation will have on the climate, the soil, and global ecology as a whole. We are facing problems because people are concentrating only on their short-term, selfish interests, not thinking of the entire human family.They are not thinking of the earth and the long-term effects on universal life as a whole. If we of the present generation do notthink about these now, future generations may not be able to copewith them.

Compassion as the Pillar of World Peace

According to Buddhist psychology, most of our troubles are due toour passionate desire for and attachment to things that we misapprehend as enduring entities. The pursuit of the objects of our desire and attachment involves the use of aggression and

competitiveness as supposedly efficacious instruments. These mental processes easily translate into actions, breeding belligerence as an obvious effect. Such processes have been goingon in the human mind since time immemorial, but their execution has become more effective under modern conditions. What can we doto control and regulate these 'poisons' - delusion, greed, and aggression? For it is these poisons that are behind almost every trouble in the world. As one brought up in the Mahayana Buddhist tradition, I feel thatlove and compassion are the moral fabric of world peace. Let me first define what I mean by compassion. When you have pity or compassion for a very poor person, you are showing sympathy because he or she is poor; your compassion is based on altruisticconsiderations. On the other hand, love towards your wife, your husband, your children, or a close friend is usually based on attachment. When your attachment changes, your kindness also changes; it may disappear. This is not true love. Real love is not based on attachment, but on altruism. In this case your compassion will remain as a humane response to suffering as long as beings continue to suffer. This type of compassion is what we must strive to cultivate in ourselves, and we must develop it from a limited amount to the limitless. Undiscriminating, spontaneous, and unlimited compassion for all sentient beings is obviously not the usual love that one has for friends or family, which is alloyed with ignorance, desire, and attachment. The kind of love we should advocate is this wider love that you can have even for someone who has done harm to you: your enemy. The rationale for compassion is that every one of us wants to avoid suffering and gain happiness. This, in turn, is based on the valid feeling of '1', which determines the universal desire for happiness. Indeed, all beings are born with similar desires and should have an equal right to fulfill them. If I compare myself with others, who are countless, I feel that others are more important because I am just one person whereas others are many. Further, the Tibetan Buddhist tradition teaches us to view

all sentient beings as our dear mothers and to show our gratitudeby loving them all. For, according to Buddhist theory, we are born and reborn countless numbers of times, and it is conceivablethat each being has been our parent at one time or another. In this way all beings in the universe share a family relationship. Whether one believes in religion or not, there is no one who doesnot appreciate love and compassion. Right from the moment of our birth, we are under the care and kindness of our parents; later in life, when facing the sufferings of disease and old age, we are again dependent on the kindness of others. If at the beginning and end of our lives we depend upon others' kindness, why then in the middle should we not act kindly towards others?The development of a kind heart (a feeling of closeness for all human beings) does not involve the religiosity we normally associate with conventional religious practice. It is not only for people who believe in religion, but is for everyone regardless of race, religion, or political affiliation. It is foranyone who considers himself or herself, above all, a member of the human family and who sees things from this larger and longer perspective. This is a powerful feeling that we should develop and apply; instead, we often neglect it, particularly in our prime years when we experience a false sense of security. When we take into account a longer perspective, the fact that allwish to gain happiness and avoid suffering, and keep in mind our relative unimportance in relation to countless others, we can conclude that it is worthwhile to share our possessions with others. When you train in this sort of outlook, a true sense of compassion - a true sense of love and respect for others - becomes possible. Individual happiness ceases to be a conscious self-seeking effort; it becomes an automatic and far superior by-product of the whole process of loving and serving others. Another result of spiritual development, most useful in day-to-day life, is that it gives a calmness and presence of mind. Our lives are in constant flux, bringing many difficulties. When faced with a calm and clear mind, problems can be successfully resolved. When, instead, we lose control over our minds through

hatred, selfishness, jealousy, and anger, we lose our sense of judgement. Our minds are blinded and at those wild moments anything can happen, including war. Thus, the practice of compassion and wisdom is useful to all, especially to those responsible for running national affairs, in whose hands lie the power and opportunity to create the structure of world peace.

World Religions for World Peace

The principles discussed so far are in accordance with the ethical teachings of all world religions. I maintain that every major religion of the world - Buddhism, Christianity, Confucianism, Hinduism, Islam, Jainism, Judaism, Sikhism, Taoism,Zoroastrianism - has similar ideals of love, the same goal of benefiting humanity through spiritual practice, and the same effect of making their followers into better human beings. All religions teach moral precepts for perfecting the functions of mind, body, and speech. All teach us not to lie or steal or take others' lives, and so on. The common goal of all moral precepts laid down by the great teachers of humanity is unselfishness. Thegreat teachers wanted to lead their followers away from the pathsof negative deeds caused by ignorance and to introduce them to paths of goodness. All religions agree upon the necessity to control the undisciplined mind that harbours selfishness and other roots of trouble, and each teaches a path leading to a spiritual state that is peaceful, disciplined, ethical, and wise. It is in this sense that I believe all religions have essentially the same message. Differences of dogma may be ascribed to differences of time and circumstance as well as cultural influences; indeed, there is no end to scholastic argument when we consider the purely metaphysical side of religion. However, it is much more beneficial to try to implement in daily life the shared precepts for goodness taught by all religions rather than to argue about minor differences in approach. There are many different religions to bring comfort and happinessto humanity in much the same way as there are particular

treatments for different diseases. For, all religions endeavour in their own way to help living beings avoid misery and gain happiness. And, although we can find causes for preferring certain interpretations of religious truths, there is much greater cause for unity, stemming from the human heart. Each religion works in its own way to lessen human suffering and contribute to world civilization. Conversion is not the point. For instance, I do not think of converting others to Buddhism or merely furthering the Buddhist cause. Rather, I try to think of how I as a Buddhist humanitarian can contribute to human happiness. While pointing out the fundamental similarities between world religions, I do not advocate one particular religion at the expense of all others, nor do I seek a new 'world religion'. All the different religions of the world are needed to enrich human experience and world civilization. Our human minds, being of different calibre and disposition, need different approaches to peace and happiness. It is just like food. Certain people find Christianity more appealing, others prefer Buddhism because thereis no creator in it and everything depends upon your own actions.We can make similar arguments for other religions as well. Thus, the point is clear: humanity needs all the world's religions to suit the ways of life, diverse spiritual needs, and inherited national traditions of individual human beings. It is from this perspective that I welcome efforts being made in various parts of the world for better understanding among religions. The need for this is particularly urgent now. If all religions make the betterment of humanity their main concern, then they can easily work together in harmony for world peace. Interfaith understanding will bring about the unity necessary forall religions to work together. However, although this is indeed an important step, we must remember that there are no quick or easy solutions. We cannot hide the doctrinal differences that exist among various faiths, nor can we hope to replace the existing religions by a new universal belief. Each religion has its own distinctive contributions to make, and each in its own way is suitable to a particular group of people as they

understand life. The world needs them all. There are two primary tasks facing religious practitioners who are concerned with world peace. First, we must promote better interfaith understanding so as to create a workable degree of unity among all religions. This may be achieved in part by respecting each other's beliefs and by emphasizing our common concern for human well-being. Second, we must bring about a viable consensus on basic spiritual values that touch every humanheart and enhance general human happiness. This means we must emphasize the common denominator of all world religions - humanitarian ideals. These two steps will enable us to act both individually and together to create the necessary spiritual conditions for world peace. We practitioners of different faiths can work together for world peace when we view different religions as essentially instrumentsto develop a good heart - love and respect for others, a true sense of community. The most important thing is to look at the purpose of religion and not at the details of theology or metaphysics, which can lead to mere intellectualism. I believe that all the major religions of the world can contribute to worldpeace and work together for the benefit of humanity if we put aside subtle metaphysical differences, which are really the internal business of each religion. Despite the progressive secularization brought about by worldwidemodernization and despite systematic attempts in some parts of the world to destroy spiritual values, the vast majority of humanity continues to believe in one religion or another. The undying faith in religion, evident even under irreligious political systems, clearly demonstrates the potency of religion as such. This spiritual energy and power can be purposefully usedto bring about the spiritual conditions necessary for world peace. Religious leaders and humanitarians all over the world have a special role to play in this respect. Whether we will be able to achieve world peace or not, we have nochoice but to work towards that goal. If our minds are dominated

by anger, we will lose the best part of human intelligence - wisdom, the ability to decide between right and wrong. Anger is one of the most serious problems facing the world today.

Individual Power to Shape Institutions

Anger plays no small role in current conflicts such as those in the Middle East, Southeast Asia, the North-South problem, and so forth. These conflicts arise from a failure to understand one another's humanness. The answer is not the development and use ofgreater military force, nor an arms race. Nor is it purely political or purely technological. Basically it is spiritual, in the sense that what is required is a sensitive understanding of our common human situation. Hatred and fighting cannot bring happiness to anyone, even to the winners of battles. Violence always produces misery and thus is essentially counter-productive. It is, therefore, time for world leaders to learn to transcend the differences of race, culture, and ideology and to regard one another through eyes that see the common human situation. To do so would benefit individuals, communities, nations, and the world at large. The greater part of present world tension seems to stem from the 'Eastern bloc' versus 'Western bloc' conflict that has been goingon since World War II. These two blocs tend to describe and view each other in a totally unfavourable light. This continuing, unreasonable struggle is due to a lack of mutual affection and respect for each other as fellow human beings. Those of the Eastern bloc should reduce their hatred towards the Western bloc because the Western bloc is also made up of human beings - men, women, and children. Similarly those of the Western bloc should reduce their hatred towards the Eastern bloc because the Eastern bloc is also human beings. In such a reduction of mutual hatred, the leaders of both blocs have a powerful role to play. But firstand foremost, leaders must realize their own and others' humanness. Without this basic realization, very little effective reduction of organized hatred can be achieved. If, for example, the leader of the United States of America and

the leader of the Union of Soviet Socialist Republics suddenly met each other in the middle of a desolate island, I am sure theywould respond to each other spontaneously as fellow human beings.But a wall of mutual suspicion and misunderstanding separates them the moment they are identified as the 'President of the USA'and the 'Secretary-General of the USSR'). More human contact in the form of informal extended meetings, without any agenda, wouldimprove their mutual understanding; they would learn to relate toeach other as human beings and could then try to tackle international problems based on this understanding. No two parties, especially those with a history of antagonism, can negotiate fruitfully in an atmosphere of mutual suspicion and hatred. I suggest that world leaders meet about once a year in a beautiful place without any business, just to get to know each other as human beings. Then, later, they could meet to discuss mutual and global problems. I am sure many others share my wish that world leaders meet at the conference table in such an atmosphere of mutual respect and understanding of each other's humanness. To improve person-to-person contact in the world at large, I would like to see greater encouragement of international tourism.Also, mass media, particularly in democratic societies, can make a considerable contribution to world peace by giving greater coverage to human interest items that reflect the ultimate oneness of humanity. With the rise of a few big powers in the international arena, the humanitarian role of international organizations is being bypassed and neglected. I hope that this will be corrected and that all international organizations, especially the United Nations, will be more active and effective in ensuring maximum benefit to humanity and promoting international understanding. It will indeed be tragic if the few powerful members continue to misuse world bodies like the UN for their one-sided interests. The UN must become the instrument of world peace. This world body must be respected by all, for the UNis the only source of hope for small oppressed nations and hence for the planet as a whole.

 As all nations are economically dependent upon one another more than ever before, human understanding must go beyond national boundaries and embrace the international community at large. Indeed, unless we can create an atmosphere of genuine cooperation, gained not by threatened or actual use of force but by heartfelt understanding, world problems will only increase. Ifpeople in poorer countries are denied the happiness they desire and deserve, they will naturally be dissatisfied and pose problems for the rich. If unwanted social, political, and cultural forms continue to be imposed upon unwilling people, the attainment of world peace is doubtful. However, if we satisfy people at a heart-to-heart level, peace will surely come. Within each nation, the individual ought to be given the right tohappiness, and among nations, there must be equal concern for thewelfare of even the smallest nations. I am not suggesting that one system is better than another and all should adopt it. On thecontrary, a variety of political systems and ideologies is desirable and accords with the variety of dispositions within thehuman community. This variety enhances the ceaseless human quest for happiness. Thus each community should be free to evolve its own political and socio-economic system, based on the principle of self-determination. The achievement of justice, harmony, and peace depends on many factors. We should think about them in terms of human benefit in the long run rather than the short term. I realize the enormity of the task before us, but I see no other alternative than the one I am proposing - which is based on our common humanity. Nations have no choice but to be concerned about the welfare of others, not so much because of their belief in humanity, but because it is in the mutual and long-term interest of all concerned. An appreciation of this new reality is indicated by the emergence of regional or continental economic organizations such as the European Economic Community, the Association of SouthEast Asian Nations, and so forth. I hope more such trans-nationalorganizations will be formed, particularly in regions where economic development and regional stability seem in short supply.

 Under present conditions, there is definitely a growing need for human understanding and a sense of universal responsibility. In order to achieve such ideas, we must generate a good and kind heart, for without this, we can achieve neither universal happiness nor lasting world peace. We cannot create peace on paper. While advocating universal responsibility and universal brotherhood and sisterhood, the facts are that humanity is organized in separate entities in the form of national societies.Thus, in a realistic sense, I feel it is these societies that must act as the building-blocks for world peace. Attempts have been made in the past to create societies more just and equal. Institutions have been established with noble charters to combat anti-social forces. Unfortunately, such ideas have been cheated by selfishness. More than ever before, we witness today how ethics and noble principles are obscured by the shadow of self-interest, particularly in the political sphere. There is a schoolof thought that warns us to refrain from politics altogether, as politics has become synonymous with amorality. Politics devoid ofethics does not further human welfare, and life without morality reduces humans to the level of beasts. However, politics is not axiomatically 'dirty'. Rather, the instruments of our political culture have distorted the high ideals and noble concepts meant to further human welfare. Naturally, spiritual people express their concern about religious leaders 'messing' with politics, since they fear the contamination of religion by dirty politics. I question the popular assumption that religion and ethics have no place in politics and that religious persons should seclude themselves as hermits. Such a view of religion is too one-sided; it lacks a proper perspective on the individual's relation to society and the role of religion in our lives. Ethics is as crucial to a politician as it is to a religious practitioner. Dangerous consequences will follow when politicians and rulers forget moral principles. Whether we believe in God or karma, ethics is the foundation of every religion. Such human qualities as morality, compassion, decency, wisdom, and so forth have been the foundations of all civilizations.

These qualities must be cultivated and sustained through systematic moral education in a conducive social environment so that a more humane world may emerge. The qualities required to create such a world must be inculcated right from the beginning, from childhood. We cannot wait for the next generation to make this change; the present generation must attempt a renewal of basic human values. If there is any hope, it is in the future generations, but not unless we institute major change on a worldwide scale in our present educational system. We need a revolution in our commitment to and practice of universal humanitarian values. It is not enough to make noisy calls to halt moral degeneration; we must do something about it. Since present-day governments do not shoulder such 'religious' responsibilities, humanitarian and religious leaders must strengthen the existing civic, social, cultural, educational, and religious organizations to revive human and spiritual values. Where necessary, we must create new organizations to achieve these goals. Only in so doing can we hope to create a more stable basis for world peace. Living in society, we should share the sufferings of our fellow citizens and practise compassion and tolerance not only towards our loved ones but also towards our enemies. This is the test of our moral strength. We must set an example by our own practice, for we cannot hope to convince others of the value of religion bymere words. We must live up to the same high standards of integrity and sacrifice that we ask of others. The ultimate purpose of all religions is to serve and benefit humanity. This is why it is so important that religion always be used to effect the happiness and peace of all beings and not merely to convert others. Still, in religion there are no national boundaries. A religion can and should be used by any people or person who finds it beneficial. What is important for each seeker is to choose a religion that is most suitable to himself or herself. But, the embracing of a particular religion does not mean the rejection ofanother religion or one's own community. In fact, it is important

that those who embrace a religion should not cut themselves off from their own society; they should continue to live within theirown community and in harmony with its members. By escaping from your own community, you cannot benefit others, whereas benefitingothers is actually the basic aim of religion. In this regard there are two things important to keep in mind: self-examination and self-correction. We should constantly check our attitude toward others, examining ourselves carefully, and weshould correct ourselves immediately when we find we are in the wrong. Finally, a few words about material progress. I have heard a great deal of complaint against material progress from Westerners, and yet, paradoxically, it has been the very pride ofthe Western world. I see nothing wrong with material progress perse, provided people are always given precedence. It is my firm belief that in order to solve human problems in all their dimensions, we must combine and harmonize economic development with spiritual growth. However, we must know its limitations. Although materialistic knowledge in the form of science and technology has contributed enormously to human welfare, it is not capable of creating lasting happiness. In America, for example, where technological development is perhaps more advanced than in any other country, there is still a great deal of mental suffering. This is because materialistic knowledge can only provide a type of happiness thatis dependent upon physical conditions. It cannot provide happiness that springs from inner development independent of external factors. For renewal of human values and attainment of lasting happiness, we need to look to the common humanitarian heritage of all nations the world over. May this essay serve as an urgent reminder lest we forget the human values that unite us all as a single family on this planet.