Saturday, July 28, 2007

Words a Chaplain Fears: Reflection on Proper 12c

I served for several years as a campus minister. Among the regulars in my campus center were several with mental health issues. I’m thinking at the moment of one in particular: a woman who lived in a retirement community close to campus. She was not herself or retirement age; but places where she might live on her full disability income were limited. Her condition included, among other things, moments of uncontrolled rage.

I received word one day from the institution where she lived that she had been arrested. She had, apparently, become angry and had attacked a woman many years her senior. The administrators felt they have no alternative, and had called the police. And, since this wasn’t her first outburst, they felt they couldn’t house her there any longer.

That same day, and well before I had really had time to think through for myself all that I had been told, the woman herself called me. “Marshall,” she said, “they put me in jail. I guess I shouldn’t have hit her, but I was mad. But they called the police, and they put me in jail. Will you come and bail me out?”

Well, when she called I just wasn’t sure what I should do. As I recall, I told her at the time I would see what I could do. But at the time I certainly wasn’t sure what to do

I certainly understood that jail was an uncomfortable and frightening place for her. I realized, too, that she had only a limited understanding in her current condition of the import of what she had done. Now she was still angry, and just wanted out!

So, what should I do? I thought about bailing her out. There is, after all, that part of me that simply wants to make people happy, and hates to see them suffering (it’s a character flaw – one that I’ve been dealing with for a long time). On the other hand, if I did, what then? She had no place to go. She couldn’t go back to the retirement community. They wouldn’t have her. I will admit that momentarily I thought about taking her in; but I was a young father with two small children, and knew that even if I didn’t realize how that might affect the kids, my wife certainly would.

I began, too, to think like a chaplain. In all probability this had happened in part because she had neglected her medications. She was, after all, not so much a criminal as a patient. If I left her, I knew what would happen: she would be taken to the state psychiatric hospital a few blocks away, and assessed. She would receive care, some therapy, new medications, and social service help to find a new place to live. Now, that wasn’t what she wanted; but it seemed to me it would get her what she needed.

Of course, her next phone call was literally vitriolic. If she was disappointed that I hadn’t bailed her out, she was incensed that I had let them take her to the hospital. Thankfully, over the next couple of weeks the third and fourth calls were easier; and ultimately she thanked me for what I had done. As she said that, I couldn’t help but think how angry she was that I had “let her down” by not bailing her out; and how sick and abandoned she would be if I hadn’t.

The Gospel passage from Luke this week is one of the hardest in the chaplain’s experience. “Ask, and it will be given to you; search, and you will find; knock, and the door will be opened for you. For everyone who asks receives, and everyone who searches finds, and for everyone who knocks, the door will be opened:” those are verses that chaplains dread. They’re right up there with, “If two or three of you agree on anything it will be given to you,” and “whatever you ask for in prayer, believe that you have received it, and it will be yours.”

And I’m sure you can appreciate why, for a chaplain, these are such frightful verses. In 27 years of chaplaincy I’ve seen entirely too many folks disappointed in their prayers. Patients and families and clergy pray, and pray pretty specifically, and don’t get what they ask. They have prayed formally or spontaneously, fervently or quietly, hopefully or anxiously; but all too often what they wanted, what they thought was best, was not what happened. That’s not to say I’ve never seen it happen. I have, and I’ve given God the praise when I did. At the same time, as I have had to tell grieving families all too often, while I believe in miracles, and have seen miracles, I’ve been a chaplain long enough to know that we don’t necessarily get the miracle we ask for at the time we ask.

And, of course, this is not just true of chaplains and it’s not just true of health care. We have all known times and places where heartfelt and fervent prayers appeared to go unanswered. That experience is a large part of the theological challenge of theodicy – the problem of pain, or the problem of evil. The real question, whatever the specifics of the circumstance, is “How did God allow this to happen;” and we’ve been dealing with it ever since.

But for all our struggles with the problem of evil, our understanding of God’s intent, and our participation in it, is reflected in what we know in Jesus. And Jesus still says in today’s Gospel, “For everyone who asks receives, and everyone who searches finds, and for everyone who knocks, the door will be opened.” We trust that God came among us in Christ, and called us into relationship with him, intending our growth and not our destruction.

I think in some ways this is a problem of proof-texting, of taking these verses out of context. The lesson begins with what we have come to call the Lord’s Prayer. Luke’s version is simpler, shorter than Matthew’s, which we use more often. It emphasizes God’s intent to provide for our needs.

And then after those verses that trouble us so, Jesus goes on to say, “Is there anyone among you who, if your child asks for a fish, will give a snake instead of a fish? Or if the child asks for an egg, will give a scorpion? If you then, who are evil, know how to give good gifts to your children, how much more will the heavenly Father give the Holy Spirit to those who ask him!”

And that, I think, holds the missing piece. When we pray, even when we pray for specific things, we are working first and foremost on our relationship with God in Christ. I talked last week about that relationship, and about God’s desire that we be real in that relationship, sharing the desires and the emotions that move us.

But for all God’s desire that we be open with him, and his intent to be open with us, he remains God. God is not simply a blessing machine, granting us what we think we want, however justified it might seem. What Christ has promised is that God will act for our good, providing a fish rather than a snake, an egg rather than a scorpion; and that whatever else God will provide, he will always provide his Holy Spirit. It is in the Holy Spirit that we encounter God in our own lives, and it is in the Holy Spirit that we discover God’s will and our participation in it.

And that is a matter of great hope, even when things seem dark. When we pray, and persist in praying, we will receive the Holy Spirit. That’s who we’ll receive when we ask. That’s who we will find when we search. That's who will open the door when we knock. God will always come to us in the Spirit, and lead us to see what he is doing in us and for us, day by day; and in the Spirit we will see ever more clearly how God is with us, and to know God’s miracles as they come.

Friday, July 27, 2007

But Not Exactly Like the Islands

I’ve been saying this to patients for years, receiving their confirmation. I’m just surprised I hadn’t already posted it.

10 Reasons why being in the hospital is like travel in a foreign land:

1. The people around you speak a foreign language.
2. They wear strange costumes.
3. They have strange and obscure customs, one of which is requiring you to wear a strange costume.
4. You’re living in a different time zone.
5. You experience a distortion of sleep not unlike jet lag.
6. The food is unfamiliar and doesn’t taste right.
7. Communication with the outside world is altered if not cut off.
8. Your cash has no meaning.
9. You’re far from family and friends; or, at least it feels that way.
10. By the time you get home, you feel more exhausted than when you left.

Thursday, July 26, 2007

Some Resources on Patient Rights

Just a quick post of resources:

Dr. Mark Meany of the National Institute for Patient Rights was kind enough to respond to my "Confessions" post. I've been looking this morning at the NIPR web site, and at the NIPR blog, "Empowering Patients." My first impression is that these are interesting sites and good resources for information and discussion. I commend them to you.

Tuesday, July 24, 2007

New Post at Episcopal Cafe

I've had another piece posted now over at Episcopal Cafe. I hope you'll take the time to read it there, and to take some time for the other, wonderful content available there now. I'm honored by the company I keep over there, and I hope you'll take some time for all of us.

Some Accessible Scholarship

In all our current theological struggles these days (and in this, when I say “all,” I think this will prove true of controversies these days far beyond the Anglican Communion), we hear again and again the words of St. Vincent of Lerins:

“Now in the Catholic Church itself we take the greatest care to hold that which has been believed everywhere, always and by all.” (emphasis in the source)

This has been quoted with such frequency that it’s been called the Vincentian Canon.

Now, whenever I hear that quoted, I respond by noting that in fact the sentence describes a null set; it has no content. If we look honestly at the history of the Church, from the Apostolic Age even to the life of St. Vincent, there is almost nothing of our developed Christian theology “which has been believed everywhere, always and by all.

In earnest of this, let me call to your attention two posts, the first two of a promised series, at “Catholic in the Third Millenium,” the blog of the Rev. Dr. Daniel Dunlap. The posts are “Ten Interesting Facts About the Struggle for the Nicene Faith,” and “Ten More Interesting Facts About the Struggle for the Nicene Faith.” These begin a concise review of the decisions of the first Ecumenical Councils in the context of wider events in the Church. Since as Anglicans we affirm the Ecumenical Councils of the “undivided Church” (at least four, and my theology professor thought we should affirm all seven), these events must certainly be of import to us. I commend these posts to your attention, and look forward for additions to the series.

By the way, you can read the Vincentian Canon in context here. I encourage all to read the passage. It is much more sophisticated in application than I think is usually credited. There is plenty here to discomfort both those who quote it too often, and those of us who think little of it. What is most important here is, I think, that St.Vincent was not writing about a fixed body of content. He was writing about theological method. That doesn’t entirely resolve the problems I see with the Vincentian Canon, but it certainly calls into question the way some have used it.

What Happened in New Orleans: Charges Dropped

I have written before of the case of Dr. Anna Pou and nurses Lori Budo and Cheri Landry, who were alleged to have participated in euthanasia in the days of disaster that followed Hurricane Katrina. Recently charges were dropped against Budo and Landry in order to obtain their testimony before the Grand Jury. Today the Grand Jury declined to bring any charges against Dr. Pou. Although the Assistant District Attorney asked for eleven counts, the Grand Jury returned a decision of “Not a true bill,” eliminating all charges. It is also reported that Dr. Pou has brought a civil suit against the Attorney General of Louisiana, Charles Foti, alleging political conflicts of interest in pursuing charges against her.

I have said that only after the Grand Jury acted could be begin to hear the facts as seen by Pou, Budo, and Landry. I hope that soon we will hear their description of those literally hellish days. I’m sure we will also hear more of the concerns of family members on which the Attorney General said he based his actions. We’ll be watching for more details.

These days the ethics of care in time of disaster is a hot topic among health care ethicists and ethics committees. One of the issues we all consider difficult but necessary to explore is “altered standards of care:” not only how one maintains appropriate standards of care in those circumstances, but how one decided what are the appropriate standards of care in those circumstances. When infrastructure is destroyed and resources are failing or nonexistent, what can you do? Andm ub thinking of what we can do, how do we decide what we should do? The “marquis question,” if you will, is, in the case of a flu pandemic, when you have a third as many mechanical ventilators as patients who might benefit from them, how do you decide who goes on one? But, that marquis question is simply one of a number of equally difficult questions that a pandemic or a disaster, whether natural or man-made, would raise. How do we as health care providers make hard decisions? And, equally important, how do we bring these to the community ahead of time so that if we need to make those decisions the community will be at least somewhat prepared?

The case of Dr. Pou and Nurses Budo and Landry won’t in itself answer those questions. However, their case and the many other cases from Katrina have given us images with which to work as we wrestle with those questions. Most important, they convict us that it can happen here, and that we must do our best to be prepared. Now, part of that is a recognition that there’s no way to really be prepared; but with that recognition comes the corollary conviction that we’re negligent if we don’t try.

Monday, July 23, 2007

Confessions of a Healthcare Chaplain

Somewhere along the thin line between Friday and Saturday, I was walking the halls of the hospital, singing the theme to “Mr. Rogers’ Neighborhood:”

“It’s a beautiful day in the neighborhood,
A beautiful day for a neighbor.
Would you be mine?
Could you be mine?”

Friday was a “chaplain night,” the like of which I haven’t had in a while. My workday began at 0830 Friday and ended at 0345 Saturday. When I was taking nights once or twice a month at the central referral hospital in my system, such nights weren’t uncommon. Since I’ve been out in my suburban community hospital they haven’t been unknown, but they have been rare.

When I was younger – say, twenty years younger – such nights were a positive joy. I have often said that chaplains are the “adrenaline junkies” of the clergy. We take on long hours, walking through emotional hurricanes, as a normal part of business. “Fools rush in where angels fear to tread;” and chaplains wade in when even fools know better. That’s not to say my colleagues in congregations are protected from such events. They happen to parish clergy, too. But for us, they are normal operating procedure, and, in the health care phrase, “standard of care.”

But they are more than that to us, too. To some extent they are marks of accomplishments, and even of machismo. As I said, twenty years ago they were a positive joy. I could work 32 hours straight and recover with one good night’s sleep. Nowadays I can’t do that; but working 20 or 24 hours, even if it takes me three days to recover, is for me recovery of past glories, not unlike someone more athletic remembering a high school football career.

Twenty five years ago I was a young priest, the Associate Rector in a large parish. I was a husband with a wife and infant son at home. I was also a very part time chaplain, taking night call at the local regional medical and trauma center once a month. Why? In part because I had already completed a CPE residency, and I wanted to keep my skills. In part because it was a significant help to a local hospital. But the real reason was that I liked it. It certainly wasn’t money. They did pay us, as we used to say, “car fare ‘ – perhaps a hour and a half at minimum wage - and they provided supper, breakfast, and a place to sleep if we could. But it wasn’t a salary, and it certainly wasn’t enough to think of it as supplemental income, even then.

No, I did it because I liked it. (I was told then, and have been told since, that I have perverse tastes.) You have to, you know. You have to want to be awakened at 2:00 a.m. to go to the bedside of a deceased patient and care for a family you’ve never met. You have to want to walk the halls at night, sustaining energy with coffee and chocolate, to share tumult and grief with the suffering. You have to like it.

And there is something there to like. Now, every profession has its moments of success and triumph. We identify it with athletics or military heroism or scientific discovery; but even those professions that seem more mundane have their moments. Think Al Pacino's character in “Glengarry Glen Ross” talking about a good sale; or Annie Sullivan in “The Miracle Worker” when Helen Keller grasps the connection between those odd finger movements and the experience of water. For the chaplain it is walking with the suffering through disaster, and especially through loss and grief, staying with them from the immediate trauma through the denial and the wailing, to help them find enough acceptance to go home and begin the next steps. And, not unlike my literary examples, the more stressful the events and the longer it takes to get there (at least up to a point), the greater the satisfaction, and even the rush, when it’s successful.

Now, I also think liking it is a matter of vocation. One of my professional stories (one I might tell at length another time) involves being in a small consultation room supporting a trauma surgeon as he told a family of perhaps twenty that the youngest adult child, the family hero, had died in an accident in a car driven by an older sibling. The family was close and intense, and their grief was explosive. All cried; many screamed; a few fell to the floor. Hospital security officers were preparing for violence, putting on leather gloves. In that chaos, I had a moment of clarity, a moment I have always since associated with the Spirit, that this was where I was supposed to be, this was what I was supposed to do. I was supposed to be with this family in their grief, to help them get past the emotional tornado to take the first steps of grieving. I waved off the security guards, and began moving through the room, praying silently as I went, to touch person after person in one way or another.

But, like all matters of vocation, and especially in identifying vocation by identifying one’s gifts, there’s also a real pleasure in doing the work. There’s a pleasure in being in the moment with people, touching them and being touched by them empathetically. If I’ve done my work well, by the grace of the Spirit, the people know I’ve loved them as best I know how in the time and the circumstances we share.

Now, I’m not particularly noble. I have to maintain some self-doubt, some awareness that because I enjoy it I can’t claim to be angelically altruistic. As I pray with some frequency, “Thank you, God, for a sense of your presence; and if it’s my own ego, my own emotions that cause this feeling, thank you anyway.”

But I will admit there was a rush, functioning as a competent, compassionate chaplain, caring for family member after family member, and watching over the staff in the process. There is a profound satisfaction in having walked through the night with those folks, seeing them off and then settling into my own exhaustion, even as I’m too wired to rest for a while. It is in its way absurd – as absurd as singing the theme to “Mr. Rogers’ Neighborhood” in the middle of the night, in the middle of a crisis, walking the hospital halls. But it is also a big and important part of what I do. I am a healthcare chaplain. It’s what I’m supposed to do; it’s where I’m supposed to be.

Saturday, July 21, 2007

Mary's Better Part: Reflection on Luke 10:38-42 (Proper 11)

I like to cook, and as a corollary, I’m a fan of cooking shows. I probably watch the Food Network more than any other channel, and the “reality shows” that hold me are “Top Chef” and “The Next Food Network Star.” I’ve been in my time a committed fan of “Iron Chef” (especially the Japanese original).

But I enjoy the instructional shows as much as anything. As I said, I like to cook; and while I don’t try everything I see, I certainly see things at times that I do want to try.

Now, some of the shows focus on entertaining; and there’s one sentence I hear a lot: “If you need to, you can do this ahead of time.” The point, sometimes stated explicitly, is to allow the cook to enjoy entertaining by being available to the guests, instead of stuck in the kitchen.

Jesus dropped in on Mary and Martha. At other places in the Gospels it is clear that Jesus knew and loved Mary and Martha and their brother Lazarus. But Luke’s description of this meeting sounds fortuitous, unexpected: “Now as they went on their way, he entered a certain village, where a woman named Martha welcomed him into her home.” (Luke 10:38) It’s as if Jesus happened to be in the neighborhood and just dropped by; or perhaps this recalls the first time they met, and Martha just opened her home to this itinerant preacher. In any case, Martha seems to have shown remarkable hospitality in opening her home.

Unfortunately, Martha found herself caught in the kitchen, unable to enjoy the party. She couldn’t be with the guests she was working so hard to care for. I can only imagine how galling it must have been at the time to hear Jesus say, “Martha, Martha, you are worried and distracted by many things; there is need of only one thing. Mary has chosen the better part, which will not be taken away from her.” (10:41b-42)

Now, over the centuries we have been certain we knew what that meant. This was a comparison of the active life and the contemplative life, and the contemplative life was clearly better. “The only think needful,” as we have seen it, was to sit at the feet of Jesus, taking in his teaching and his person. Martha had chosen many tasks, all of which seemed to make sense at the time; while Mary had chosen the one apparently unhelpful task of being a good disciple.

We know that interpretation well; but tonight as I sit, typing away, I wonder whether we’ve missed something. No, let me be more clear: I think we have missed something. Because, you see, the essence of true welcome is not in what we do for those who come to us, but how we meet and interact with those who come to us. Like the host of the cooking show who encourages us to “do this ahead,” this passage calls us to see that hospitality is more a matter of personal encounter than of personal service. And so the “better part” that Mary chose was to be with Jesus, to be present to him as a person. Martha’s efforts were noble, perhaps, but they withheld the one gift that only she could offer to Jesus: herself.

I think there is some support for this in the Genesis lesson. This is the famous story of Abraham at Mamre, meeting the three men who will speak to him in the voice of God. There is really the same distinction here between Abraham and Sarah as there is between Mary and Martha. True, Abraham leaves his guests long enough to give appropriate instructions to Sarah and to the household; but he seems to do that as quickly as possible so as to return and be present to his guests. And surely he was really present to his guests. After today’s lesson, when two of them leave to assess the sinfulness of Sodom, Abraham has the sense of openness in the relationship to negotiate with the third, knowing he was negotiating with God, over the lives of the Sodomites. What came out of this encounter was not simply good service to guests, but a good relationship, one that could sustain tough arguments even with God.

In many ways this is counterintuitive for us. We may honor contemplative Mary, but we do it as much in the breach as in the observance. We may set aside some time for quiet and reflection; but for most of us it is a small portion. For all our apparent criticism of Martha, we are more likely to focus on her activity. Even in my profession, where we speak often of the importance of “being” rather than “doing” (a chaplain joke: “Don’t just do something! Stand there!”), it’s all too easy to get caught up in function instead of the encounter with the patient as person. We scoff at those who are “so heavenly minded as to be no earthly good,” and so neglect what we think of as Mary’s “better part.”

But that takes us away from more than just listening to Jesus. It takes us away from being present to Jesus. We preach that God sought not just obedience from us, but relationship with us. After all, why make us sentient, why make us free of thought and will – why make us human – if all God wanted was properly programmed robots? Why give us the capacity for relationship, if not for us to live in relationship with God. We identify the Trinity as relational, and our capacity for relationship as part of what it means to be made in the image and likeness of God. We claim the importance of prayers of intercession and lament as well as prayers of praise and contemplation, and sing of sharing “all our sins and griefs,” and not just waiting for what we might hear.

No, I think perhaps Mary’s “better part” was not simply basking in the presence of Jesus, taking in his every word. Her better part was to be present to Jesus, to establish a relationship with Jesus that, according to John’s Gospel, would allow for mutual grief every bit as hard as Abraham’s negotiations. Martha’s loss was not simply contemplation, but interaction and conversation and relationship – personal relationship for which the best of service is no substitute.

We say that part of being Christian is a “personal relationship with Christ;” and a relationship, even with Jesus, is a two-way street. All our business, like Martha’s, separates us not only from being in the presence of Jesus, but also from being present to Jesus. This Gospel calls us not just to hang around Jesus, but to offer ourselves fully in relationship. Let us, like Mary, choose the “better part,” a full relationship with Christ, trusting that it will not be taken away from us.

Thursday, July 19, 2007

Health Care Chaplains and Health Care Issues in the News

Well, between the incipient presidential campaigns (or have we already gone too far for to call them that?) and Michael Moore’s latest opus, health care is back on everyone’s radar. With that in mind, let me bring to your attention two articles worth reading and reflecting on. (And thanks to Episcopal Cafe, among others, for pointing these out.)

The first is a New York Times article (July 17, 2007) on the work of a chaplain. Titled “Offering Comfort to the Sick and Blessings to Their Healers”, it focuses on the work of one particular chaplain, the Rev. Margaret Muncie. Peggy is a valued colleague and a dear friend. The article offers a snapshot of her work; but those of us who know her, and know our professions, recognize that this offers only a glimpse. On the other hand, working in a ministry that often has difficulty distinguishing itself from other ministries gives me an appreciation of even a glimpse shared with the general public.

The second article is from Reuters, and is titled, “When to let go? Medicine's top dilemma.” The article is concerned with hard decisions about health care when death is probable and modern medicine is offering less and less benefit to the patient. Health care professionals struggle to recognize when care is truly therapeutic (likely to help with healing), and when care becomes futile (perhaps holding a status quo or slowing decline, but no longer truly therapeutic). As hard as they struggle to discern that threshold for themselves, they can find it even harder to discuss this with patients, and with families of patients who can no longer speak for themselves. We all saw this in excruciating detail in the case of Terri Schiavo in 2005, but these issues are wrestled with on a daily basis in health care institutions across the country.

I have written before of General Convention statements on health care, and especially at the end of life; and of a report to the 2006 General Convention on medical futility and a resolution that arose from that (a resolution that was, as I say, “Windsored:” so much time was taken in responding to the Windsor Report that this and other resolutions weren’t completed). The Reuters article brings this issue to the fore once again. Every opportunity we have to raise and reflect on this is worth taking

Sunday, July 15, 2007

Another Voice on Universal Access to Health Care

As interested as I am in universal access to health care, it may surprise you that I haven’t yet seen “Sicko.” Fact is, I tend to resist seeing movies that everybody thinks I ought to see. I’ve never seen “Passion of the Christ;” but, then, I’ve read the book many times, so that’s little loss. I do think I’ll get around to seeing “Sicko”, though – eventually.

That said, let me bring to your attention a recent interview that used “Sicko” as an opportunity to reflect on the American health care system (or lack thereof). Last Monday, July 9, on “Fresh Air,” Terry Gross interviewed Jonathan Oberlander. Oberlander is an Associate Professor at the University of North Carolina, Chapel Hill, teaching in the Social Medicine and Political Science programs. He is author of The Political Life of Medicare. He makes some interesting points.

He suggests, for example, that there are other models of national health care systems that we haven’t been looking at. He doesn’t believe that the United States will commit to a single-payer plan, much less truly socialized medicine, as in the models of Canada or Great Britain, respectively. He suggests, instead, that we might look at Germany and Australia, which have incorporated commercial insurance companies into national health care programs

He also points out that in our existing structure (I resist calling it a “system,” and I work in it), requiring standardized procedures of all insurance companies would save a lot of money without affecting health care. As a corollary, he asserts that one of the greatest expenses in health care is in underwriting costs: the time and money spent determining whether the patient qualifies for care, and what care the patient might qualify for.

This is forty minutes well worth your time. There is some consideration and critique of the movie, but it’s primarily an opportunity to reflect on health care in the United States. As we work toward recognizing a right to health care in this country, new voices with new ideas are always welcome.

Monday, July 09, 2007

The Passion of Archbishop Gomez

I have read the address of Archbishop Drexel Gomez to the General Synod of the Church of England. I encourage that it be read in full. I’m not going to do a point by point analysis, but I do have some reactions to share.

First, I will say there is much in here to appreciate. Archbishop Gomez argues passionately for the Covenant process, and for the first Draft produced by the Design Group he chairs. He makes some comments that I think will be helpful. His expectation that there will be at least two more Covenants, developed over some time, is an important comment. So is his recognition that there are already voices critiquing the current Draft, and that there are more voices to be heard. His reference to the recognition by some that the Draft is too centered on the Primates, and has too little voice for the laity, is reassuring, if not enough to change my opinions.

I think the Archbishop does describe the state of the Communion pretty well. He is remarkably clear in distinguishing concerns from facts. Note, for example, this passage:

Rumours abound that there are plots to carry forward in some provinces a bold agenda on gay marriage, and to require toleration of it across the Communion. Other rumours inform us that the primates are plotting to impose a “collective papacy” on the Anglican Communion. Bishops and archbishops are taking over the care of churches outside their own provinces; new jurisdictions are being erected and bishops are being consecrated and set up in a spirit of competition. People are taking up more and more extreme positions and then defending them; no matter how well founded or sincere the objections.

The allegations that progressive Anglicans want to force something on traditionalist Anglicans are only that: allegations; and “rumors” is as good a word to describe them as any. And, notwithstanding that there have been voices from a few Primates that seem to elevate the Primates’ Meetings to a conciliar if not a curial standard, concerns of progressives that this is what most primates want are no more than rumors, either. On the other hand, boundary crossings and “interventions” are facts, as are the voices that have elevated rumors to projections.

I disagree with some of the Archbishop’s descriptions and assessments of his own work. My reassurance at the statements I cited above notwithstanding, my reading of the plain text of the Draft Covenant as it is does not show me an adequate description of what it means to be Anglican, or an accurate description of the functions of the Instruments of Communion. The Draft does not describe accurately what I have inherited as an Anglican. It does indeed propose inordinate authority for the Primates’ Meetings. It introduces this and other innovations into the life of the Communion. As it stands now, I continue to see this Draft, and especially reaching to the Primates’ Meetings as the central forum of the Communion, as choosing a bad expediency, driven by a false urgency. (You can read my reflections at greater length, look under “Labels” and select “Study Guide.”) I appreciate his expectation of further discussion and revision; but I will reserve judgment on the process until we see a final draft.

Perhaps the most interesting piece of this speech is his argument for the concept of a covenant within the tradition of God’s people. Once again, he argues passionately and articulately (and, I think, accurately) that covenants have been essential moments in our history as Christians. His articulation of Biblical tradition and current agreements will still beg for some the question as to whether we need another covenant. That is, if we can all recognize that we all participate in the “new covenant in my blood,” do we really need a contemporary articulation on paper to which we all append our signatures? However, his description of the situation is, I think, apt: “I have no doubt that it would be lovely to go back to a day when we relied on no more than the affection generated by our mutual inheritance and care. But I’m afraid that those days have gone….”

And that, I think, will be the tragedy of Archbishop Gomez. The facts he recognizes, that mutual non-recognition exists among provinces of the Communion, made incarnate in impaired communion and provincial boundary violations and new bishops for new quasi-diocesan entities, may well have already gone too far. The Covenant process as first envisioned in the Windsor Report, and for which the Draft has been prepared, may well founder on the hard coasts of primates and other provincial leaders who do not care to wait, to pursue a process of several drafts and more than several years. He argues passionately and reasonably for a process that may well not be capable of accomplishing what he wishes: thirty-eight provinces with roots in the Church of England coming to some agreement of what it means to be Anglican, and of how we will relate to one another. Terms may be reached – I believe will be reached – but some will agree to one set of terms, and some to another. It’s looking more and more like there when the dust settles there will be more than thirty-eight “provinces,” but fewer – perhaps far fewer – than thirty-eight in any one communion. He will, I fear, experience that other meaning of “passion”: he will put his heart into a goal that cannot be reached. He will suffer disappointment and grief, and we will all be suffering with him.

We are an Easter people. I am an Easter person, and I do believe that from all this turmoil and from the radical change – the loss - of the Communion-as-we-have-known-it we will see God raise a new manifestation of his Church. I believe God will work in all of us, and all of us will, by God’s grace, see some sort of new birth, even if we have no idea yet quite what it will look like. But before we can get there, we will experience passion – passion as emotional investment and passion as suffering. I fear Archbishop Gomez will be disappointed, as we will all be disappointed, in the changes that will come. It is by faith, trusting in the covenant God has always established with us in Christ, that we will go on to see new birth.

The Church of England Responds to the Draft Covenant

The General Synod of the Church of England is meeting, and has discussed the Draft Covenant proposed by the Covenant Drafting Committee. So, this is the resolution passed in the current meeting:

‘That this Synod:
(a) affirm its willingness to engage positively with the unanimous recommendation of the Primates in February 2007 for a process designed to produce a covenant for the Anglican Communion;
(b) note that such a process will only be concluded when any definitive text has been duly considered through the synodical processes of the provinces of the Communion; and
(c) invite the Presidents, having consulted the House of Bishops and the Archbishops’ Council, to agree the terms of a considered response to the draft from the Covenant Design Group for submission to the Anglican Communion Office by the end of the year.’

As you might guess, weeping and wailing and gnashing of teeth has begun, coming from all quarters. (Thanks to Thinking Anglicans for this; and scroll down through the posts there for the past week or so to see position statements pro and con.)

However, it seems to me that this is actually quite a measured and even minimal response. “To engage positively with… a process designed to produce a covenant,” is little more than the Episcopal Church committed to in General Convention in 2006: ” as a demonstration of our commitment to mutual responsibility and interdependence in the Anglican Communion, [to] support the process of the development of an Anglican Covenant that underscores our unity in faith, order, and common life in the service of God’s mission....” (Resolution A166) It expresses a commitment to a process, without presuming whether the actual result will be acceptable or accepted.

That next point is also worth noting. The General Synod resolution emphasizes more than any other statement I recall that no Covenant can be presented as final by any of the “Instruments of Communion.” Not even passage by Lambeth or the Anglican Consultative Council establishes a new Covenant. Only “the synodical processes of the provinces of the Communion” can establish any Covenant as in any sense “official.” It’s not clear whether that would require all, or at least a majority of the Provinces, but it would certainly be true for any individual province.

Finally, the designated response from the Church of England is arguably quite minimal. There is a commitment for the Archbishops of Canterbury and York, with consultation from the House of Bishops, to “agree to the terms of a considered response to the draft from the Covenant Design Group.” While this does not rule out a proposal to accept the current Draft as is, neither does it rule it in. Indeed, there has been sufficient disagreement among voices within the Church of England as to make it difficult for a “considered response” to make such a commitment.

It appears there are folks who would have been just as happy if the General Synod has said nothing at all, if in the best and most formal language. This statement is certainly not “nothing;” but neither is it capitulation to any specific draft of an Anglican Covenant, including the one currently presented. This commitment from the General Synod is not really so different from that of the General Convention of the Episcopal Church. That similarity is remarkable, in and of itself – remarkable, and perhaps reassuring. The General Synod has called the Church of England to be measured, considered, and not hasty in response to the Covenant Process, and especially to this Draft.

It is said that the Mullah Nasruddin was once overheard bragging that he was such a good teacher that he could teach even a donkey to speak. This was reported to the king, who called the Mullah before him and demanded on pain of death that he prove his outrageous claim. The Mullah bowed low and agreed, but noted that he needed ten years for the process. The king accepted this and sent him away.

Later a friend came to commiserate. “Surely you are terrified! If you don’t accomplish the impossible task you will surely die.”The Mullah replied that he was not that concerned. “We are old, the king and I,” he said, “and ten years is a long time. In ten years the king may die, or I may die, or the ass may learn to speak.”

The General Synod has committed the Church of England to think and respond, to participate in a Covenant Process to produce a Covenant that will take years to be received through the Communion. In the time that will take a number of other events may well supersede the concerns we have today.

Saturday, July 07, 2007

Who's Minding the Store?

You may have noticed that I haven’t been posting quite as fast lately. I have spent much of my time for the past month or so reviewing Patient Rights Standards of the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO).

Perhaps it would help to say something about what the JCAHO is, and why it's important to many hospitals. First, it's important to know that health care institutions of all types are subject to review and inspection. Such reviews are sometimes euphemistically called "surveys." They involve onsite inspections for adherence to relevant laws, regulations, and standards. For the institution they are always intense experiences, and can sometimes be quite adversarial. Surveys may come from state authorities, the Centers for Medicare/Medicaid Services (CMS), or any of a number of professional credentialing or certifying organizations.

Part of the reason these surveys can be difficult is that some organizations and some surveyors can get very specific, not only about goals to be accomplished, but also about procedures to accomplish them. The problem with that is a lack of flexibility. Patients should be cared for according to "best practices." However, "best practices" are often subject to debate among professionals. Health care professionals base decisions on published information from various sources reflected against their own clinical experience. But, the published information can change literally weekly, with every publication of an important journal, or with papers presented at important professional conferences or new reports from the National Institutes of Health.

And, each professional's practice is unique. Application of best current information has to be individualized to each patient; and over time that will result in practice patterns individualized to each professional's patient pool and practice environment.

So, with a constant flow of new information, reflected in the specifics of each practice, freedom to adapt and change is important. Regulations and regulators who are too prescriptive and specific may not provide the best care for patients. They can certainly become frustrating for conscientious professionals.

That's how the Joint Commission came to be. A group of physicians, with support from their professional organizations, thought they could offer a better way. They agreed to the need for rigorous goals for patient care. However, they thought that being too prescriptive wasn’t helpful. They brought a different model: they allowed institutions to determine for themselves how they would meet the appropriate goals. The survey would focus on whether the processes an institution chose actually accomplished the goals – were there appropriate policies in place, and appropriate practices to implement them, with staff knowledgeable about them and consistent in applying them? In addition, they chose to encourage ongoing work for performance improvement: how was the institution paying attention, tracking policies and procedures; and how was the institution working constantly to get better? The goal was that surveys would still demonstrate that an institution was offering quality care, but would be less adversarial. Indeed, there was some hope (and some success) that surveys would become educational. Surveyors could share good ideas they had observed in other institutions, and so could help institutions constantly improve.

JCAHO is not the only organization in health care surveying for quality care and practices. However, the JCAHO does have one characteristic that its competitors don’t share: “deemed status.” Under an agreement between JCAHO and CMS a hospital accredited by JCAHO is deemed to have met its CMS requirements for up to three years. Between the less prescriptive, less adversarial survey experience and “deemed status,” JCAHO is a service that hospitals and other health care institutions value highly, and pay well for.

Yes, institutions pay for the privilege of being surveyed by the JCAHO. They don’t have to. They’re not charged for the regular state surveys, or for CMS surveys. On the other hand, those surveys are definitely prescriptive, and all too frequently feel adversarial. Accreditation by an independent organization can be a marketing asset, as well as keeping the institution on its proverbial toes. Add to that the advantage of “deemed status,” so that the hospital experiences a JCAHO survey every three years rather than a CMS survey every year, and it can be well worth the money.

That said, it’s still a lot of work. Some of the work – much of the work, when things are working right – is maintaining daily the best practices and procedures. But, of course, for hospitals, like practitioners, the environment is always changing. In addition to the issues I’ve already mentioned of new information, there are other things going on. There is more and more pressure to provide information about the quality of care and make it available to the general public. Information on a number of quality measures is already available on the website of the Department of Health and Human Services at Hospital Compare. Other information is available from the JCAHO itself at Quality Check. JCAHO has also established a series of National Patient Safety Goals for its accredited institutions, and new measures have been added to that each year since it began. So, with all that in mind, JCAHO Standards change from year to year, and there’s a certain amount of work adjusting to the changes.

And the hospital has to be ready at all times. Surveys are unannounced. That is, we get about 30 minutes notice. We have some approximate idea, knowing that we can expect something at least three years from our last survey. In the past those triennial surveys did have some notice, although not really enough to make significant changes, or even to hide any problems. On the other hand, they have always reserved the right to drop in any time. On top of that, members of Congress raised questions about “deemed status,” and about whether the relationship between JCAHO and its accredited institutions was too chummy. They leaned on CMS, and CMS leaned on JCAHO; and so all surveys became unannounced.

So, the work never stops. And since I am Chapter Leader for the hospital on Patient Rights and Organizational Ethics Standards, now and again I have to commit a block of time to reviewing changes in Standards, and in monitoring our performance. I will admit it can feel pretty tedious; and yet I can see the ethical import of each Standard and the expectations it entails.

That’s part of the work of a chaplain that I didn’t know about at the beginning. Had I known twenty years ago that I’d be so deep in administration, I don’t know that I’d have gone back into full time chaplaincy. However, over the years I’ve learned two things. One is that, dull and removed as the administrative stuff might seem, if it doesn’t get done and done competently nothing else does either. The second is that if I want to reach the greatest number of people, I need to move beyond direct care to shaping the whole culture of health care, so that spiritual care permeates the whole enterprise.

So, if it seems I’ve been a bit behind, and you’ve been wondering who’s minding the blog store, it’s because I’ve been deep into the hospital’s process of who’s minding the store.

Friday, July 06, 2007

Some Other Folks Reflecting on "Spirituality"

In a recent post we have had some reflection on changes in the language of chaplaincy, using the category "pastoral" less and the category "spiritual" more. Take the time to read this excellent post with its comments at the blog "Faith and Theology." It's all relevant, and especially to some of the comments to my post. (Thanks to Jason at Gower Street for pointing to this.)

Thursday, July 05, 2007

What Happened in New Orleans: Part 2

There is some new news about the charges of euthanasia against a physician and two nurses in the aftermath in New Orleans of Hurricane Katrina. Nurses Lori Budo and Cheri Landry and Dr. Anna Pou were alleged by the State Attorney General of Louisiana to have killed patients at Memorial Medical Center. The allegations were that they went beyond palliative care, beyond providing medication for pain and discomfort. Sometimes the efforts at palliation end up overmedicating a patient and the patient dies; but the intent is not to kill, and the death is an unintended consequence. The allegations in this case were that these three women had different intent, essentially intent to end life expeditiously, without the incremental approach, the investment of time, that demonstrates the intent simply to control pain and symptoms.

Now, District Attorney for New Orleans Parish has refused the charges against nurses Budo and Landry. That is, he will not take the case and will allow the charges to drop. The intent is apparently to compel their testimony before a Grand Jury. According to the New Orleans Time Picayune, their attorneys are concerned that they might still be subject to state or federal charges issued independently.

It is unclear what this might mean for Dr. Pou. Charges against her have not been refused, and one might conjecture that the point of compelling the testimony of the nurses is to focus responsibility on the physician. On the other hand, the Grand Jury could decide, based on their testimony, that the efforts were palliative in intent and in execution, and that therefore there are no grounds for charges against any of the three.

The basis for determining that palliative care that ends in death is not homicide is the moral principle of “double effect,” or the “second unintended consequence.” I have written before of how important to health care in general is the principle of “double effect;” and also of how I think we need to approach it with humility, if not with fear and trembling. The circumstances at Memorial Medical Center after Katrina were extreme to say the least. The patients were not the only ones suffering with heat and fatigue. To pursue justice in any meaningful sense requires that we hear the story in detail.

However, without testimony we will have little information about how events actually played out. At the time I noted that we knew very little about the facts. Many of us have an interest beyond the academic in the details, because these issues are part of our practice, if, thankfully, in much more controlled circumstances. We are watching and waiting to know the full history of these three practitioners and the patients under their care.