Episcopal Chaplain at the Bedside

Political Thought for the Day (1.25.12)

2012-01-25T22:38:00.001-06:00

If we want progressive government, it is not enough that we have a progressive president (even so moderate a progressive as President Obama). It's not even required.

If we truly want progressive government, we need a progressive Congress. More specifically, we need a 2/3 majority in both houses - 292 or more in the House and 67 or more in the Senate.

Think what that would mean. If President Obama is re-elected, he has an overwhelming majority, and especially one that can resist a filibuster in the Senate. If President Obama is not re-elected (heaven forefend!), that is a majority that can not only resist a filibuster, but can override a presidential veto.

And note that I haven't associated this with a specific party. There are some troublesome regressive Democrats; and there are certainly out there some progressive Republicans (well, at least there used to be). The issue isn't party, but progressive goals.

So, if we want progressive government, we need a progressive Congress. And it's time we focused on that. The regressives learned this long ago; which explains why we have the Congress we have today.

First Do No Harm; Nor Allow It To Pass Unnoticed

2012-01-12T22:58:00.000-06:00

For more than ten years now a central theme in the lives of hospitals and health care professionals has been patient safety. It has always been a concern, but a significant step was a report from the National Academy of Sciences titled, "To Err is Human: Building a Safer Health System" (linked from here). This study noted how often patients were put at risk, and then sought to identify the causes. According to the Report Brief,

One of the report’s main conclusions is that the majority of medical errors do not result from individual recklessness or the actions of a particular group--this is not a “bad apple” problem. More commonly, errors are caused by faulty systems, processes, and conditions that lead people to make mistakes or fail to prevent them. For example, stocking patient-care units in hospitals with certain full-strength drugs, even though they are toxic unless diluted, has resulted in deadly mistakes.

Thus, mistakes can best be prevented by designing the health system at all levels to make it safer--to make it harder for people to do something wrong and easier for them to do it right. Of course, this does not mean that individuals can be careless. People still must be vigilant and held responsible for their actions. But when an error occurs, blaming an individual does little to make the system safer and prevent someone else from committing the same error.

The report has been very influential, as we’ve sought to improve the safety and the experiences of patients. Of particular importance has been a “non-punitive workplace.” To improve the system requires continuing improvement; and continuing improvement requires data. More specifically, improvement requires identifying problems and mistakes. After all, that information provides the best direction to take to improve the system. Improvement actually requires that staff report problems, and especially errors. To encourage that reporting, healthcare institutions elected to establish a non-punitive workplace. That is, to encourage reporting staff have been told that they could report mistakes without fear of being fired, so that the system could be improved to prevent such mistakes. The efforts at improving the system required that staff report their errors.

And unfortunately it appear that the reporting isn’t happening. A new report was released last week from the Office of the Inspector General of the Department of Health and Human Services titled, “Hospital Incident Reporting Systems Do Not Capture Most Patient Harm.” (you can link to the report from here; and to a New York Times article here). Worse, it appears that the reporting systems fail precisely because the people on whom they rest, the professionals who make or see the problems, don’t know what to report. As it was reported in the Executive Summary:

Hospital staff did not report 86 percent of events to incident reporting systems, partly because of staff misperceptions about what constitutes patient harm. Of the events experienced by Medicare beneficiaries discharged in October 2008, hospital incident reporting systems captured only an estimated 14 percent. In the absence of clear event reporting requirements, administrators classified 86 percent of unreported events as either events that staff did not perceive as reportable (62 percent of all events) or that staff commonly reported but did not report in this case (25 percent).

In a way, this finding concerned me more:

For the 62 percent of events not reported because staff did not perceive them as reportable, administrators indicated that staff likely did not recognize that the event caused harm or realize that they should complete a report. The most common reason administrators gave for staff underreporting was that no perceptible error occurred (12 percent), indicating that staff commonly equate the need to complete incident reports with medical errors. Other reasons for underreporting include staff becoming accustomed to common occurrences and therefore not submitting reports, such as events that were expected side effects (12 percent) or occurred frequently (8 percent). (Emphasis mine)

Or as the report says in another paragraph, “Although administrators indicated that they want staff to report all instances of harm, when asked about specific events administrators conceded that staff may often be confused about what constitutes harm and is, therefore, reportable.” (Again, emphasis mine)

In one sense, that seems troubling. The determination of harm would seem to be measured based on what did or what could happen to the patient. But, then, that becomes one of the points of decision: if what could happen didn’t happen, was the patient harmed? Or, if it’s an expected or frequent side effect, does the fact (or the assumption) that benefits to the patient exceeded risks mean that the patient isn’t (“isn’t really”) harmed? While we would think that harm would be pretty easy to identify, it may not always be so clear to the professional in the circumstance at the time.

The OIG report recommends the development of a list. That could certainly be helpful. The risk, of course, is that what we see as harmful today may not be an issue in the future; and that the list may soon be dated and inadequate.

At the same time, we do need to pay close attention. Reporting of these incidents that either harm patients or come close to harming patients is dependent on the professionals serving them. I know that they want patients to do well, and to have things go right. It is important that they also recognize what to report when things don’t go right. Once again, that’s the only way that we’ll know where the issues lie, and what we need to improve.

On Bull Riding and Baptism: Reflections for the Feast of the Baptism

2012-01-08T22:07:00.000-06:00

As I was preparing to preach on the Feast of the Baptism, I was also listening on my computer to professional bull riding. I commented on that on Facebook, and one of my friends wrote, “Could be an interesting sermon.” This or something like it was my sermon for the Feast of the Baptism, Year B.

My Best Beloved and I have been fans of bull riding for some time. It began some time ago, when she was studying veterinary technology. Just as she was working through her large animal rotation I discovered bull riding on television. We started liking the bulls – magnificent animals! And then I began watching the riders themselves. I’ve spent a career in hospital work. I’ve seen folks in the ER with all kinds of traumatic injuries. So, watching bull riders take falls and blows from bulls that ought to put them into intensive care; and then to see them get up and walk out of the arena, was just astounding.

One thing you see quickly when you watch bull riding (and let me be clear: I am not nor have I ever been a cowboy. I am a fan, but watching is all I’ve ever done) is that the bull rider is fully committed. He gives it everything trying to complete those eight seconds (and, yes, there are women bull riders, but they don’t get on television). They put their bodies, and literally their lives on the line. They are, as they say, all in.

Which brings me back to baptism. We believe that we are baptized, as we say, into the baptism of Christ – baptized into his death and resurrection. Our understanding is that, once baptized, we are all called to be fully committed, and to put it all on the line.

That is, of course, the model we have in Jesus. He was baptized by John, embracing a baptism for repentance, embracing in that sense all sin, including ours. He saw the heavens ripped apart, he saw the dove, and he heard voice of God: “You are my son. I’m happy about this.” From there, as we recall, he went on until he put his life on the line for us. From his baptism, Jesus was certainly all in.

And so we are also called to be fully committed, and to model our whole lives on Christ. That’s what we say at every baptism. Indeed, that’s why we baptize our children, so that they can grow into Christ from the very beginning. We, too, are called to be all in.

Now, one thing that bull riders say over and over is that bull riding is really a mental game. It doesn’t look that way. It looks like it’s a serious physical challenge. The fact is, though, that all those guys are strong and agile and fit. All of them have bodies that put most of ours to shame; and yet some ride, and ride for years, when others do not. All of them fall off of bulls – most of the time short of their eight seconds – and yet they get up again and again and again. That’s about mental determination, about heart.

Which is also part of what baptism is about. We believe that in baptism we receive the Holy Spirit and are strengthened for our lives in Christ. When Jesus was baptized, there was the Spirit, seen as a dove. When Paul reached Ephesus, he found a congregation that had heard of Christ. They had even been baptized, but only to repent of their sins. He baptized them himself, and laid his hands on them, and they did receive the Spirit; and immediately they found themselves empowered in ways they hadn’t imagined before.

So it is as we are baptized into Christ. We also receive the Spirit, there to empower and guide us in our lives in Christ. That’s especially important when we fall short. And we certainly will fall short. We will have our own times when we lose our grips and are thrown off. We will fail to meet the standards we set. None of us has the discipline, the strength – either physical or mental – to always live up to our model in Christ. When we fall, the strength to get up again comes from the Spirit. The voice that calls us and says, “yes it hurts. Yes, it’s hard; but you can get up and you can start again,” is the voice of Christ’s Spirit pleading with our spirits. And without that Spirit, we would surely be lost.

And so there are indeed parallels between bull riding and baptism. From our baptism, we are called, as Jesus was, to be fully committed, to be all in. From the time we come through the water, just as when Jesus came up from the water, our world is torn open and God says to us, “You are my child, and I’m happy about this.” We are empowered by his Spirit to model our lives on Christ. And when we fall short, it is Christ’s Spirit that gives us the strength and courage to pick ourselves up out of the dirt and try again. We have been baptized with the baptism of Christ. We have been baptized into his death and resurrection. We have been called and empowered to model our lives on Christ; and like our model, we have been called to be all in.

Latest on Endorsement for Healthcare Ministries.

2012-01-05T15:09:00.000-06:00

The Episcopal Church has completely revised its web site. So far, I think there's a lot of promise there.

That said, one point that was missed in the first days was information on healthcare chaplaincies. Episcopal chaplains across the country have made their concerns about this known to folks at the Episcopal Church Center. One special concern was accessing on line the application form for Endorsement for Healthcare Ministries. Now the form is available, and you can access it here. Instructions on completing it, and on whom to send it to, are on the form, and those haven't changed.

I know that searches about Episcopal or Anglican Chaplaincy, and especially about Endorsement, are among the most frequent reasons that people find this blog. With that in mind, I wanted to have this information current and available. I'll keep track, and if there are further changes I'll let folks know.

In These Days of Advent

2011-12-18T16:40:00.001-06:00

My Advent piece is now up at the Episcopal Cafe. Yes, I know it will be Christmas soon; but it's still Advent now. In fact, if you'll go read the piece, I think you'll want to hang onto these last days of preparation. It isn't Christmas until it's Christmas. Don't jump ahead.

While you're there, as always I encourage you to take a look at the many other great essays and news items and opportunities for reflection that make up the Cafe. Take some time. Leave a comment. At the Cafe we want to offer some of the best of the Episcopal Church. We hope you'll feel we're successful.

"I Read About This Case...."

2011-12-12T22:55:00.000-06:00

Just how valuable is anecdotal evidence? In my world, “anecdotal evidence” refers to the individual interesting story. In a world that is shaped – or at least believes it is shaped – by research, anecdotal evidence is interesting, but not all that valuable. They are almost always interesting, but usually too exceptional to be useful.

Unless, that is, it’s brought up by an anxious family member. In that case, it is a moment to grasp at slim hope; and in that case, the story almost always begins something like, “I read about this one case….”

So, it caught my attention when this AP story showed up in my paper. While they are not the whole content of the story, it is built around two exceptional young women. They share the distinction of each having weighed less than ten ounces, and having lived to tell about it (so to speak). They have had remarkably few ongoing health problems. They are perhaps as exceptional a pair as we might find in any set of health statistics.

And the article does note that. Early on the reporter notes,

A medical report from the doctor who resuscitated the infants at a suburban Chicago hospital is both a success story and a cautionary tale. These two are the exceptions and their remarkable health years later should not raise false hope: Most babies this small do poorly and many do not survive even with advanced medical care.

It would be more true to say, “most do not survive with advanced medical care.” The article notes the research of a physician who tracks data on this, and says that, “about 7,500 U.S. babies are born each year weighing less than 1 pound, and that about 10 percent survive.” Which is to say, of course, that 90 percent die, even with all the medical technology that we can bring to bear.

The article notes that this is especially important in trying to determine at what point a fetus is viable. This is an important consideration in two hot questions in medical ethics. The first is when it is or is not appropriate to treat. That is, what is the point after which all the medical technology might benefit this new child, and before which it won’t – and so arguably isn’t worth putting this new child through. All the medical technology is scarce and expensive; and while there is resistance to the idea of rationing that care, it’s a reasonable question whether there are circumstances in which it would be wasteful.

The second hot question is abortion. In efforts to regulate abortion, and especially after the first trimester, many states have sought to identify some point of “viability,” some point in gestational development after which most fetuses (and in application any individual fetus) will probably survive, and so should have some measure of legal personhood – enough at least for the state to defend.

The difficult thing is that these cases don’t really help us know about viability. Yes, they have survived, and indeed have thrived; and, like other anecdotal evidence, they are too exceptional to be really useful.

That doesn’t mean, though, that these stories won’t come up. Such stories always come up. It is at that point when physicians and other health professionals need to step beyond simple statistics. It is at that point when they have to become more specific and discuss why this case – this person, this fetus, this patient – is more likely to be on the 90 percent and not in the 10 percent. That’s not an easy task. It almost always involves telling people something they don’t want to hear, something that emotionally they may not be able to hear.

At the same time, it’s what we have to do (and I say “we” advisedly; because helping hear what they’ve been told is also part of what a chaplain might be called to do). It’s all we can do. Our best information and our best medical guidance is all we can offer in response to this opening: “I read about this one case….”

The Good News Really Is Good News: Reflections for Advent 3, Year B

2011-12-10T19:27:00.000-06:00

From the lessons for this Sunday, the 3rd of Advent:

“The spirit of the Lord GOD is upon me,
    because the LORD has anointed me;
he has sent me to bring good news to the oppressed,
    to bind up the brokenhearted,
to proclaim liberty to the captives,
    and release to the prisoners;
to proclaim the year of the LORD's favor….” (Isaiah 61:1-2a)

Wait a minute! Don’t we hear that somewhere else? Of course! We hear if from Jesus.

“When he came to Nazareth, where he had been brought up, he went to the synagogue on the sabbath day, as was his custom. He stood up to read, and the scroll of the prophet Isaiah was given to him. He unrolled the scroll and found the place where it was written:
‘The Spirit of the Lord is upon me,
   because he has anointed me
     to bring good news to the poor.
He has sent me to proclaim release to the captives
   and recovery of sight to the blind,
     to let the oppressed go free,
to proclaim the year of the Lord’s favor.’” (Luke 4:16-19)

So, this Sunday as we find ourselves in the story just before the public presentation of Jesus the adult (that is, just before the baptism and, in John, the encounter with the first disciples) and in the church calendar just before the celebration of Jesus the infant, we also find ourselves just at the beginning of Jesus’ public ministry, at least as recorded by Luke. In the context of Luke, we would say that this is Jesus’ opening description of his own ministry. Surely to those who heard Jesus in the synagogue at Nazareth this would bring to mind not just the memory of Isaiah’s prophecy, but also the context in which he prophesied. He prophesied to folks who had returned to Jerusalem, only to find that it wasn’t all that they had hoped. So in Jesus’ time Jerusalem was not all that the people might hope: occupied by Roman troops, ruled by cooperation – one might even say conspiracy – between a Roman governor, a puppet king, and the religious establishment, but certainly not by God.

In the midst of that confusion, that darkness, John comes baptizing and preaching. When representatives of the religious establishment come and ask, “Who are you,” all he says at first is who he is not: “Not Messiah, not Elijah, not even the prophet predicted by Moses.” Whoever he is, he finds more important who he is not. “I’m one calling you to prepare. Another is coming, greater than I, and I am not worthy to be his slave.”

These days as we look at a world that is not all that we might hope – wars and rumors of wars, economic injustice, and a world apparently ruled by those whose first question is, “What’s in it for me and mine” – we are called to be people of hope. We are called to proclaim as Jesus did that God’s intent is good news and health and freedom and restoration. We are called to proclaim the time when the Lord’s grace will rule all, when all things will be set just as God intends. It isn’t necessarily easy, and it won’t always be heard. That doesn’t matter. Jesus confirmed what Isaiah proclaimed: that God’s plan is for wholeness and restoration. In our generation, it’s our vocation to pass that on.

Another Chaplain's Voice

2011-12-01T21:35:00.000-06:00

I'm always interested in another blog about health care chaplaincy. There just aren't that many. However, I've discovered another. Check out The World of Pastoral And Spiritual Care. The author is a rabbi and chaplain in New Jersey. The posts and citations are interesting. So, give it a read.

Remembering That Insurance Isn't Necessarily Enough

2011-11-27T22:33:00.000-06:00

A friend picked up on this video on YouTube:

If you don't know Elizabeth Warren, it's time you did. She was President Obama's choice to establish the new Consumer Financial Protection Bureau, intended to monitor investment practices on behalf of the general public. She got the Bureau established; but when the President wanted to nominate her as its first head, Republicans in the Senate made it clear she could never be confirmed - a telling point, if one can be known by one's enemies. She is now running for the Senate herself.

Her point in this video: even those of us with insurance can be bankrupted by medical expenses. This isn't the result of any one factor. However, with all the various reasons for this, it remains a cautionary tale. Take a few minutes to watch.

On God and Job Descriptions: Reflections on Proper 17A

2011-11-08T10:22:00.000-06:00

Yeah, I know this it a bit behind. It's been an interesting autumn. But, more about that another time.

Most of us – certainly, all of us who are adults – have at one time or another been through the process of hearing a job description. It might come as part of a job interview. It might come as part of a peer review process, or perhaps an annual review. But one way or another, most of us have listened to a detailed job description.

Which is, really, what happened to Moses.

Now, Moses had been coping with a serious identity problem. Was he a Hebrew slave? Was he an Egyptian prince? All of this came to head when he killed that Egyptian overseer – something that would make sense for a Hebrew slave, but which only an Egyptian prince could get away with. That was the reaction the next day of the other Hebrews: “Who are you? You’re nothing but a murderer!” Then he fled to Midian. There he married a preacher’s daughter, and became a shepherd. Hebrew slave, Egyptian prince, murderer, shepherd – that has to be an identity crisis to end all identity crises!

So, there he was, out in the wilderness with the flock, when he sees the bush; and it’s burning – except it’s not. It’s flaming – yet nothing goes to coal or ash. “This,” he says, “I’ve got to see.” He turns aside, and when he gets close enough, God calls to him: “Moses, take off your shoes. You’re standing on holy ground.”

And then God gives Moses a job: “I’ve seen how my people suffer at the hands of the Egyptians. I’m going to bring them out; and I’m going to send you to do it.”

Now, this is pretty basic as a job description – but Moses wants none of it! He starts to crawfish, coming up with every reason he can think of that he’s not the right person. He doesn’t speak well, and he doesn’t make much of an impression. First and foremost, he says, “Who am I to go? More important, when they ask, who can I say sent me?”

And God answers: “I am who I am;” or, “I will be who I will be;’ or, perhaps, “Is-ness. And that will be my name forever.”

But for all of that, Moses wants nothing to do with it; and won’t, until God eliminates all his objections. But, this got me to thinking: Moses doesn’t sound all that much like someone we’d accept into the ordination process. After all, when bishops and Commissions on Ministry and seminaries think about who they might consider for ordination, they tend to think about someone who is confident and competent, and certainly not someone with a serious identity crisis. They look for someone who can function independently. When I was in the process, they were looking for “a self-starter.” Fifteen years later, the phrase was “a change agent.” Recently, I’ve heard that the goal is someone who is “entrepreneurial.” And there’s a point to all of this. Most clergy are in one-person positions, or perhaps part of a small staff. The capacity to act independently has its value.

But, Moses wasn’t very “entrepreneurial.” He wanted nothing to do with this job, at least not at first. And yet look what God did with him!

We get caught up in these images of what things are supposed to look like, and especially what leaders are supposed to look like. That was Peter’s problem. He had just proclaimed that Jesus was the Messiah and the Son of God; and Jesus had proclaimed that this confession would be the foundation for the new body. And then he went on to give the job description, to say what being Messiah would mean. It would mean journeying to Jerusalem, where it would mean arrest and torture and crucifixion and death, and then resurrection. But as we know that didn’t fit Peter’s image of the Messiah. Wasn’t the Messiah supposed to raise up Israel again, and, not incidentally, to through out those oppressive Romans and those awful Greek-speaking pagans? So, he took Jesus, pulled him out of earshot, and said, “Wait a minute! Don’t tell them that! God forbid that should happen!”

But Jesus answered so that everyone could hear: “Get behind me, Satan. You are deceived and deceiving. You’re seeing things the way everyone has always seen them; but God sees them differently. And if you can’t see things right you’re a hindrance to me and not a help.”

He went on, “If you want to follow, you need to take up your own cross and follow. If you try to hang on to the life you’ve had, you will lose it. If you will let go of that life for me, you’ll discover new life that you haven’t imagined.”

So, Jesus laid out a new understanding of what it meant to be Messiah, one that included torture and suffering and death; and he laid out a new job description for his disciples. Peter was convinced it was all wrong. He wanted nothing to do with this new job. But, look what God did with him!

The thing is that this is entirely consistent with how God does things. Time and time again God takes someone who isn’t at all entrepreneurial, who often enough is unprepared and uninterested, and in and through that someone carries out God’s purposes. God takes folks who are unexpected and uninspiring and sometimes just flat incompetent, and does wondrous things with them. Those folks we think of as great heroes of the faith didn’t start out heroic at all. That’s just how God does it.

Which ought, I think, to make us both hopeful and anxious. It ought to make us hopeful because these are folks like us – like me. I have to admit that one of my favorite canticles in the Prayer Book is one we largely hear in Lent. I feel quite connected to the Song of Penitence, with its verse, “I have sinned, O Lord, I have sinned,/ and I know my wickedness only too well.” I think if we’re honest, we are all aware of our shortcomings. We can be hopeful to think that God can do wonderful things in and through folks like us – and usually does!

And that’s what might make us anxious. If God can work through folks like us, then we need to consider that God is always calling folks like us – that God is always calling us. Sure, that call doesn’t often come in some great and mysterious event; but it certainly will come. And we are people who say we will respond. Every time we attend a baptism in the Episcopal Church, and at Easter and other times, we say again and again that “We will, with God’s help.” We trust that God in Christ is calling, and we have committed to answer when we hear. In the Baptismal Covenant we have heard, if you will, a job description; and we have committed to the job.

Blessedly, rarely are we called to lead God’s people out of slavery into freedom; but we are called. And few of us will see a burning bush; but we will hear God call. And when we hear we can trust that God can work in us, because God has always worked in folks like us. From a Hebrew mother, who put her child in a basket because she was required to throw him in the river, to a teenage girl, who said to God’s messenger “I will do what God asks;” from a frightened shepherd with an identity crisis to a confused fisherman who, until after the resurrection, can’t keep his foot out of his mouth; God has worked in folks like us to carry out God’s purposes. So when God calls, we need not worry that we’re not good or competent or entrepreneurial or heroic enough. God can do wondrous things through folks like us. God always has.

Spiritual Assessment in Three Questions

2011-10-20T20:13:00.000-05:00

The following article was was published in PlainViews, the online journal for chaplains, on October 4, 2011. (Vol. 8 No. 17) I was happy for the publication. However, since PlainViews is a subscription journal (only limited articles are available for free), I'm aware that many may not have seen the article. Now that the next edition has been released (10/19/2011 Vol. 8 No. 18), I am now posting the article here.

A further note about PlainViews: while full access requires a subscription, many chaplains find it a worthwhile resource, and well worth the cost. You can find subscription information here. If you'd like to see the kind of articles PlainViews provides, you can find many earlier articles at the PlainViews' Legacy Archive Page. Peruse and see for yourself the quality of the material available.

Any profession must take on the task of setting standards of practice, and chaplaincy has been no exception. Especially important for chaplaincy has been the concept of spiritual assessment or diagnosis. Beginning with Paul Pruyser’s book, The Minister as Diagnostician, those of us in the field have been thinking about, and working to develop, means of assessing the spiritual condition and needs of a patient.

That’s not as simple to do as it is to say. What are the appropriate categories? What sort of language works, and how applicable is it to all patients? Especially difficult in our predominantly theistic and even Judeo-Christian culture (yeah, the institutions may be losing influence, and even coherence, but the vast majority of Americans say in surveys that they believe in God or a Higher Power) is coming up with forms that aren’t Judeo-Christian, or even theistic; because there are more folks around than we used to see for whom those categories don’t work.

I have been working for some time with my own system, and have taught it locally. I would also like to share it with and receive comments from colleagues.

I believe that those aspects of our lives that we might call “spiritual” can be discerned through three questions (with gratitude to Douglas Adams, author of The Hitchhiker’s Guide to the Galaxy series). The first:

“What do I believe about Life, the Universe, and Everything?” Is God, or is God not? Is the universe sensible and aware, or mechanical? Are events random, or somehow organized? Does the arc of the universe bend toward justice, or are we alone in the vast, soul-sucking emptiness of space?

The second question:

“Who am I, in light of what I believe about Life, the Universe, and Everything?” Am I the paragon of creation, or a worm and no man? Am I the result of a million years of random chance, or of God’s creative intervention? Am I alone or in a community?

The third question:

“How ought I to act, based on who I am, in light of what I believe about Life, the Universe, and Everything?” Am I accountable; and if so, to whom? To God? To my fellow human beings? Only to my own conscience? Do I base my actions on principles, or on my emotions? Am I to do unto others as I would have done to me? Or, am I to do unto others before they do unto me?

As a shorthand, I think of the questions as “Reality, Identity, and Morality.” I think these questions can allow us to appreciate the spiritual circumstances of those we serve, and whether they are properly or maladapted.

Consider, for example, these questions, heard often enough by chaplains: “Why is God doing this to me? What did I do to deserve this?” The questioner believes in God, and believes that God is engaged in creation. Specifically, the questioner believes that God attends to this person, who is individually important enough to God to be under direct judgment. The questioner believes that he or she has some agency, which he or she may have misused, and so is accountable. So, just from these two questions we have some sense of the patient’s Reality, Identity, and Morality.

Alternately, consider this comment: “I’m not really religious. I just try to be a good person.” This suggests that the person believes that creation is orderly and not random, and that the person is a participant with meaningful agency. Indeed, this person believes that behaving properly is sufficient, and that there is no need to participate in a religious community to live in a meaningful way.

These are the categories that help me assess a patient’s spiritual status. With them I am able to develop a plan based on supporting the patient’s self awareness and helping the patient adapt to circumstances so as to live appropriately within the patient’s own beliefs. As the concept of adaptation and function are central to the practices of nursing and other ancillary services, it communicates will with other professions. It is simple to apply, and can be based on the patient’s own comments, without requiring interrogation. Finally, it is respectful of the diversity of our contemporary culture.

Hearing From Another Chaplain: After the Crash

2011-10-13T13:11:00.000-05:00

I've been quiet for a while. I took two and a half weeks of vacation, and between prep time before leaving, and recovery time after returning (a recovery that is still a work in progress!), I haven't had much blog-able in my head, much less time and energy to get it typed and posted.

But I am beginning to catch up, and today took a few minutes to look at some sites I hadn't visited in a while. In the process, I returned to Susan Palwick's blog, Rickety Contrivances of Doing Good. In addition to being an academic and the author of works of science fiction, Susan is an Episcopal lay minister and serves as a volunteer chaplain in her local Emergency Room. (Which is why there's always a link to her blog on my blog.) That ER is in Reno, Nevada, recently notable for the disaster at the air races. Susan responded to that mass casualty, and posted her reflection on her blog. I would encourage you to go and read it. I know it's been a while now since the event, but her thoughts are absolutely pertinent.

In health care institutions, and especially in hospitals, we drill regularly to prepare for such events. Such a drill is part of what has complicated this first week back. We drill to have our people and our processes prepared; but, blessedly, such events are actually rare. Whenever a colleague has such an experience and shares about it, it's worth our time to read and reflect. So, go over and take a look a what Susan experienced that morning and learned from her experience. It may well be valuable for you, too.

Rationing? What Rationing?

2011-10-03T22:40:00.000-05:00

When discussion comes up of government support for universal access to health care, sooner or later an opponent will say, “That will lead to rationing of health care.” Well, there were two stories today on NPR’s “Morning Edition” that clearly demonstrate that rationing is happening right now.

The first story is about drug shortages. Although I’ve written before about “orphan drugs,” drugs that aren’t profitable for pharmaceutical companies because there are too few patients who need them (although they need them critically) to make a profit, these shortages aren’t of those drugs. They’re about labetalol, a well established drug for controlling blood pressure; and the form of calcium that’s used in IV parenteral nutrition; and a well established drug for ovarian cancer. The difficulties have to do with how few manufacturers there are for many of these drugs. But whatever the cause, the result is the same: decisions have to be made about which patients get the drugs and which don’t. In some cases – perhaps in most cases – there may be a substitute to offer. Often, however, the substitute isn’t as effective, or isn’t as cheap; and sometimes there isn’t a substitute to offer. One way or another, decisions are made about rationing care.

The second story is about the a case presented to the Supreme Court of the U.S. today, the first day of the new Court season. The state of California lowered reimbursement to physicians under Medicaid. However, Medicaid is jointly funded by the state and the Federal Government, and the law requires that such changes be approved by the Center for Medcare/Medicaid Services. At first, the changes weren’t even submitted; and when they were, they weren’t approved. They were put in place anyway, and so patients and providers, both hospitals and physicians, filed suit.

Now, the legal issue before the Supreme Court today was whether it was legal for the plaintiffs to sue. However, in the meantime the result is rationed health care. Medicaid doesn’t pay for all the costs of care (that’s not just an occasional problem; it’s part of how the reimbursement is set) so as to encourage providers to control costs. However, like any other good, you can only cut so much before you start doing damage. The patients who don’t get care because doctors can’t afford to provide care (and, yes, in many cases won’t afford – because, remember, the reimbursement doesn’t cover the costs) are the damage. Costs are “controlled,” and care is rationed.

Now, I won’t pretend: I know that care will be rationed, almost whatever program we provide. However, we can make the decisions haphazardly; or we can have the politically difficult conversation to set community standards about how we will ration. Or, I suppose, we could decide health care is a right, and make the political decision to provide it, including determining how to adequately fund it. Nah, that will never happen.

So, yes, I understand that rationing will happen. I just get annoyed when folks want to pretend that it isn’t happening right now.

Yes, Virginia, There Are Evangelical Episcopalians

2011-09-13T22:08:00.000-05:00

Among the many places where I'm connected is LinkedIn. If you're not familiar with it, it's much like Facebook, but with an entirely professional focus. Like other social networking sites, there are topical groups, including one for folks interested in the Episcopal Church. This week one member posted this question: "Are there any fellow evangelical Episcopalians out there?" This was my answer.

I think there are evangelical Episcopalians - by which I mean folks who experience Scripture as central to their faith, and who experience joy in living before Christ and sharing that with others, both within and without the congregation. Few of them are thorough-going Biblical literalists; but most believe the Gospels faithfully relate the experiences of the Evangelists with Christ, and that at least most of the events described, including the miraculous events, are historical.

By and large, they are not tied to a particular style of worship, although they enjoy some "praise" music. As the Prayer Book since 1979 has emphasized the Eucharist as normative Sunday worship, they have the Eucharist on Sundays, and not Morning Prayer. At the same time, most don't attend congregations where the liturgy is chanted most Sundays, or where incense is used, unless for Easter or certain special occasions.

Some of them are uncomfortable about decisions that the General Convention has made. However, they feel established in and supported in their individual congregations, and pastorally supported by clergy even when they disagree with them; and so they continue in the Episcopal Church. They see things changing around them, and regret some of the changes; but they have enough hope in Christ that they don't feel they have to fight things they can't control.

I spend half of my Sundays supplying in one church or another in two adjacent dioceses, and I meet these folks all the time. I'm happy they're with me in worship.

I know that the word "evangelical" when applied to an Episcopalian or other Anglican has meant something a little different: a literal use of more of Scripture, especially on social issues; a more exclusivist understanding of salvation; and, unfortunately, anti-Episcopal Church sentiments at home, and that plus anti-American culture sentiments abroad. However, I will stand by this as more accurate to the evangelical Christian tradition as folks live it out in the Episcopal Church; and I'm happy to have them with me in worship, and in my diocese, and in the Episcopal Church.

Remembering the Martyrs of Memphis

2011-09-09T13:00:00.000-05:00

Many of my readers will be aware that the Episcopal Church remembers on certain days persons who have been especially noteworthy as models of the faith. Today is the day of Constance and her Companions, the Martyrs of Memphis. It is a day I make note of each year because the Martyrs of Memphis demonstrated their faith, and most of them died, providing health care.

Memphis, Tennessee, was wracked by yellow fever epidemics three times in ten years. The third epidemic occurred in August of 1878. 30,000 citizens – those who had somewhere else to go – fled the city. 20,000 had nowhere to go, and were forced to face the plague. Deaths averaged 200 per day, and before it was over more than 5,000 had died. The city was so depopulated that it lost its charter, and was not reorganized for fourteen years.

There were those who stayed by choice to care for the sick. The Episcopal Church remembers specifically six Episcopal nuns; four Episcopal priests, two of whom were physicians; a third physician; matrons at an Episcopal School for girls; and volunteer nurses and clergy from as far away as New York. However, we also remember that there were laypersons from many of the faith communities in Memphis who stayed: Roman Catholic, Baptist, Methodist, Presbyterian, Jewish, and other clergy and lay workers. They stayed to serve the sick, and died for their compassion. In Memphis today this is an ecumenical remembrance, when all faith communities commemorate one another’s honored dead as they remember their own.

In the last decade we’ve seen so much to make the commemoration of the Constance and her Companions more apt and poignant. We have seen cities wracked with expressions of human evil. We have seen images of another city, a sister city on the same river, emptied of people and filled with sickness and death. We have seen the entire region leveled by storm after storm, storms that continued to rage long after the wind and water appeared to have subsided. This year alone we have seen disaster after disaster, from the devastating tornadoes in the Central Plains; to more flooding in the Missouri and Mississippi Valleys; to the floods in the Northeast and Midatlantic states from hurricane and tropical storm. And we see colleagues providing care, often at great personal risk, to rescue those who can be saved from disease and dehydration, and from the inertia of isolation and shock. We support them in spirit, with our resources, and for many of us, with our prayers.

The Martyrs of Memphis are a part of the heritage at my hospital and health system. While we are not all Christian, much less Episcopalian, we are all in the tradition of health care. Watching the consequences of these events, we know that risks to the health of our communities are risks to us. We continue to serve, knowing of costs we hope we will never have to face. We serve those who come to us, knowing we are not immune ourselves. There is real courage and commitment in our service, and it is the same commitment shown by the Martyrs of Memphis of all faith backgrounds and of none.

As an Episcopal Chaplain, I consider each of my colleagues in health care to be holy and all of their works to be sacred. The compassion and commitment each of them shows reflects, I believe, the compassion of God. Today, as I honor the Martyrs of Memphis, I honor and pray for them; for each of them witnesses to individual faith at personal risk and cost, and reflects the presence of care here at in my hospital and health system, and in the whole of God’s creation.

Remembrance

2011-09-09T10:07:00.001-05:00

There is a wonderful article today from the Episcopal News Service speaking to the work of chaplains on September 11, 2001, and in the days after. You can read the article here.

As we remember that day ten years ago, we can remember those noted in the article, and so many more. Quite a few Episcopal chaplains and other clergy and lay ministers assisted in New York; while many of our colleagues in military chaplaincy assisted in both New York and Washington, and so many places around the world. I remember the late Mike Stewart, then Treasurer of the Assembly of Episcopal Healthcare Chaplains (AEHC), who served in the Office of the Bishop Suffragan for Chaplaincies (now the Bishop Suffragan of Federal Ministries) to coordinate efforts in New York and the Episcopal Church’s efforts at disaster response. I think of Peggy Muncie, who walked virtually the length of Manhattan for the opportunity to serve (and those of us who know Peggy have some idea of what that took). I think, too, of our colleagues in other traditions. After all, the first victim identified from the disaster was a New York Fire Department Chaplain, Fr. Mychal Judge, a Roman Catholic priest and Franciscan friar. Many of us served as well in our own places, caring for the families of those lost and those affected; caring for our own frightened staff members and parishioners; and praying for God’s guidance in the midst of fear and grief and confusion.

In fact the Executive Committee of AEHC was scheduled to meet in New York on September 14 and 15. We talked and wrestled with what we should do, what duty required of us at that point. Ultimately, we did not meet, which relieved our own families (in my household the words "baseball bat" and "kneecap" came up in the same sentence). However, AEHC members played our parts in cooperating with the National Office in responding to these disasters, and preparing to respond to the next.

As we remember this anniversary through this weekend, may God grant that we humans of all creeds will be guided more and more to love neighbor as self; and when we fail, may God continue to call chaplains to step forward to care for the fearful and the suffering, and for those who serve their needs.

When Your Sibling Sins Against You: Reflections on Proper 18, Year A

2011-09-05T22:26:00.000-05:00

This sermon or something like it was preached September 4, 2011, at St. Mary Magdalene Church, Kansas City.

You can run on for a long time
Run on for a long time
Run on for a long time
Sooner or later God'll cut you down
Sooner or later God'll cut you down

If you were paying attention to the lesson from Ezekiel, you can understand why this song came to mind. “I have appointed you,” says God, “if I have sent a word through you, you are to proclaim it. If you proclaim it, and they don’t pay attention, they’re still accountable, but you are not. But if you fail to proclaim it, they are still accountable, but so are you.”

And you know that all around us, and all across the world, that is the subject of the sermon. I bet you could throw a rock, and hit a church where this is being preached: “Tell them that God’s going to cut them down!” And any of us who have heard that sermon – and who among us hasn’t heard that sermon? – know that they have a laundry list. They have a guidebook to give them the list of sings to talk about.

Go tell that long tongue liar
Go and tell that midnight rider
Tell the rambler, the gambler, the back biter
Tell 'em that God's gonna cut 'em down
Tell 'em that God's gonna cut 'em down

And I have a problem with that. I don’t them they’re on the right track. I don’t think they’re paying attention to what Jesus said.

That’s not to say that we couldn’t talk about sin. I thought about preaching about sin. The thing is, I don’t really think there’s that much to say. Paul gave us the important handle on sin when he quoted Jesus, who quoted Leviticus. Paul said, “Love your neighbor as yourself. All the other commandments are covered if you love your neighbor as yourself.” And that’s the point. We could actually talk for a long time about sin. We could talk about original sin, or about sin as part of the environment we live in, or about the fallenness of creation. But at some point it comes down to this loving neighbor as self. The point where we experience sin is when someone fails to love us as we think they would love themselves – or when we fail to love someone as we would love ourselves.

And so we come to the Gospel. Jesus is talking to the disciples, to the gathered community. “When a brother sins against you…” – note that the word here is “brother.” Jesus is talking about siblings in the community, in the Church. I think we need to hold these things together. The word in Greek is “brother;” and while we think of it as a sibling in Christ, we need to appreciate that is applies when our relationships are at their most intimate. That’s when our sins are most difficult. It is when those closest to us fail us that we are most hurt; and when we fail those closest to us that we are most guilty.

And in that moment, Jesus tells us to do something difficult: “When a brother sins against you, go to that person individually; because if you can reconcile at that point, you’re saved the relationship.” Of course, our reaction is, “Lord, do I have to? Can’t I just let this slide? After all, it wasn’t that bad. That person isn’t that bad. Can’t we just let that pass?”

But, Jesus says to go, to reach that person, to save that relationship. It’s important to see this in context. The paragraph before this Gospel lesson is Jesus telling the parable of the lost sheep. “Don’t lose any of these little ones,” he says. “If you have a hundred sheep, and one goes missing, you leave the ninety nine and go looking for that one, however hard it is. And if a brother sins against you, go to him individually to try to save the relationship.” It’s about saving the relationship, about reconciling with that sibling in Christ. And if it doesn’t work one on one, take two witnesses with you – but not as witnesses about how God’s going to – well you know the song. Take two persons to witness how committed you are to saving the relationship. Take them for consultation to show how far you’ll go, even to the point of hearing about yourself. And if it still doesn’t work, take it before the whole congregation. And if you still can’t reconcile, then treat that person like a Gentile or a tax collector.

Now, once again this is a place where I think folks go wrong. There are Christian communities that take this very seriously – Anabaptists and others. It is important to involve the congregation. Confession is before the whole congregation. And if the person won’t confess, then the congregation treats them “ as a Gentile and a tax collector:” they cut them off. We call that shunning.

But as much as I respect their commitment to the faith, I think once again they’ve missed the point. Specifically, they’ve missed just how Jesus treated Gentiles and tax collectors. Like the tax collector that Jesus called to be one of the Twelve. Like the Gentile woman who taught Jesus that messiahship went beyond the people of Israel. Jesus didn’t cut off Gentiles and tax collectors. He reached out to them. He partied with folks that others wouldn’t be seen with, tax collectors and prostitutes, and said his mission was especially for them. He didn’t cut them off. He continually went after them.

And so it is for us. If we are to treat them as Jesus treated Gentiles and tax collectors, then we can’t cut them off. Even if with the support and consultation of the entire congregation the relationship can’t be reconciled, you don’t just give up. You keep trying, you keep hoping, you keep praying. No, it may not work. But like Jesus, you don’t give up. And he has promised us that, even when it isn’t working, Jesus will be with us.

Now, we are surrounded these days by folks that seem more interested in who God will cut down, or at least who must be cut off, than in bringing folks together. It has become a part of our political discourse. It has infected the debates among some Christians. It is all around us, and so many for one reason or another want to work out, not how to reconcile, but who to shun.

And we know that reconciliation can be difficult. Every one of us has someone around that each of us considers the most stubborn person in the world. (I won’t give the list of those who think that of me!) Sometimes it can seem easier to just give up.

But, that is not how Jesus has instructed to us. When your sibling in Christ, however close, sins against you, do what you can to reconcile. Try it in person. Get consultation. Get consultation even from the whole congregation. And if after all of that you can’t reconcile, don’t give up. Keep trying, keep hoping, keep praying. And trust that Jesus wll be with you. Whenever two or three are gathered, Jesus will be with you. Even when it isn’t working, even when you can’t reconcile, even when you’re the one who did the sinning, remember that he said he would be there whenever two or three are gathered. So, when your sibling sins against you – and certainly when you sin against your sibling – work to reconcile. Keep trying, keep hoping, keep praying; and trust that, even when it doesn’t seem to be working, know that Jesus will always be with you.

Sermon Prep, and Identity Crisis (Updated)

2011-08-17T11:58:00.002-05:00

I’m looking at the lessons for Proper 16, for this coming Sunday, using the Genesis lesson for the Old Testament. One thing stands out for me immediately: there’s something important about personal identity in this.

Look, for example, at Moses. Was there anyone more set up for an identity crisis? Born of a Hebrew mother, nursed and raised by her, but as an Egyptian prince – is it any surprise that he will find himself very conflicted when he grows up? If you think about it, his confusion comes into focus with his murder of an Egyptian overseer brutalizing a Hebrew slave (something that is, unfortunately, skipped in the lectionary course). Is he the prince, with power of life and death? Or is he the Hebrew, defending his enslaved brother? Even the slave he saves will ask him, “Just who are you?” Is it any surprise that he will have to run away, in a sense to leave both identities, before he can encounter God and so find himself?

And then there’s Jesus’ question to the Twelve: “Who do you say that I am?” We know Peter’s response, because we know the story; and because we know the story, we think we understand what Peter’s response means. But, did Peter and the others? After all, Jesus tells them to keep it a secret – something that must have been a real trial for them. And he gives Peter, whether personally or as representative of the Twelve and so of the community, the Church, a specific role as the foundation of what will come after, with authority to speak for God: “Whatever you bind is bound, and whatever you free is freed.” Just who were they to have this authority, authority that they couldn’t tell anyone about?

And identity is central to Paul’s metaphor for the Church as Christ’s body. “I say to everyone among you not to think of yourself more highly than you ought to think, but to think with sober judgment, each according to the measure of faith that God has assigned.” That’s a real challenge to a community that has been given authority from God to bind and to free. “How do you know who you are, except in the concept of the Body and your specific vocation in it?”

So, while it may not be all about identity in these lessons, that issue is there. Who are we, if we are in this world but not of it? Who are we, if we are citizens of the Kingdom? Who do we say Christ is, and what does that say about who we are as Christ’s body? Sunday is yet a long way off, at least in how I prepare a sermon; but this is where I am today.

Update: I dashed this off today after reading the lessons, and then discovered this post at Miriam's Tambourine from Memphis Theological Seminary (and a hat tip to The Text This Week). I had not read this, but, seeing as it's been available a while, it was clearly written first, and we share a theme. Having lived in Memphis at one time, I have great respect for the folks at MTS. So, you might it to your reflections.

2011-08-16T13:28:00.000-05:00

I have written a number of times of the importance for chaplains of being “research informed.” I’ve also written of the difficulties with this, and especially of knowing what we’re reading when we’re reading the research of other professions.

Well, this past week various news sources (for example, here and here)have noted a paper whose authors noted a troublesome trend. The paper itself was presented this spring at the Annual Conference of the Association of College and Research Libraries. Titled, “Retracted Publications in Biomedicine: Cause for Concern,” it was written by John M. Budd, Zach C. Coble and Katherine M. Anderson, all of the University of Missouri.

The paper is not that long, and is a straightforward read. I encourage you to read it. However, some of the problematic results are easily presented. The authors identified more than 1100 studies retracted in the twelve years from 1997 to 2099 by various journals (retractions noted in PubMed, the on line citation source of the National Institutes of Health). Of those retracted, fully 55% were for misconduct. Some of these showed up in the news, but most did not. They note that it is a small percentage of all published research, but it's more than enough. More troubling is they're comparison to an earlier study. In that study, using the same methods, Budd et al discovered that in the years from 1966 to 1996 235 articles were retracted, 40% for misconduct. So, in almost a third the time, almost five times as many articles were retracted, and the proportion retracted for misconduct increased by 15%!

The authors go on to point to several related causes for concern. One is just how long it takes for a retraction to be issued. In the study reported this spring, the mean time to retraction was 17 months. On the other hand, for the median (half took less time and half took longer) was 29 months and the range went to 304 months – more than 25 years! (Yes, that’s only one exceptional article; but still….) In all that time people could be and were put at risk, either in larger studies designed on faulty premises, or in treatment programs that proved unsound.

Even more troubling for the authors were the number of times retracted articles were cited after they had been retracted. Citations before retraction might be unfortunate, but they’re not in themselves evidence of poor practice. Citations after retraction, on the other hand, are – or may be. If a researcher is searching an online database, or looking at the online edition of the journal, it may be easy to see that an article has been retracted (if not always why). However, if the researcher is going from one print source to another – say, looking at the hard copy of a journal based on a citation in a book or other printed source – the fact that the article has been retracted won’t be immediately available. Budd et all note that “Finding a retraction statement does require some diligence on the part of authors and editors.” Much depends on how online sources make retractions apparent, and most make some effort. However, the individual researcher needs to check carefully.

We have a lot at stake these days in the quality of research that gets done, and especially, as Budd et al note, in biomedical research. Across the spectrum of healthcare, from providers to payers to patients, quality of care and demonstrated outcomes are critical. But demonstrated outcomes require good research that is careful about methods, resources, and ethics. Mistakes in research are unfortunate, but not entirely avoidable. On the other hand, misconduct in research unethical and sometimes dangerous. Compounding misconduct by poor review processes or slow retractions is also unethical, as is citation of retracted research. We all have a lot at stake in this. We as the recipients of research need to be able to trust that we’re receiving good information; and we who are researchers (and yes, chaplains are researchers, too!) need to be worthy of that trust.

Healthcare: It's Where the Jobs Are

2011-08-11T21:44:00.001-05:00

The website Health Leaders Media posted on Monday a brief story analyzing statistics from the Bureau of Labor Statistics. The headline says a lot: Healthcare Sector Drives U.S. Job Growth.

The article notes, “Healthcare created 31,300 new jobs for the month and 170,900 new jobs in the first seven months of 2011. The healthcare sector has accounted for 18.4% of the 930,000 non-farm payroll additions in the overall economy so far this year, BLS preliminary data show.” The July increase is more than a quarter of all new jobs created in the economy. The latter point is despite the fact that hospitals lost 2,000 jobs in June, and that there were losses in July in long term and other care facilities. It represents more than four times the jobs created in health care in 2010 in the same time period. New jobs were evenly distributed largely between hospital and ambulatory care, with slightly more in ambulatory care.

That’s tremendous job growth, both for one month and for the year to date. Which raises a question for me. In a time when jobs are short, and people everywhere in the economy are looking for signs of growth, healthcare is showing great promise. Moreover, jobs in healthcare are good jobs. They pay well, and have some staying power. They can’t be outsourced overseas (and won’t, I think, be affected all that much by medical tourism), and the market is only growing, both as the population grows and as it ages.

So, why, then, is there so much interest in cutting reimbursement for healthcare? I know that it’s expensive (after all, I’m not just a provider; I’m also a consumer), but I also know that, like other forms of maintenance, preventive care is an investment that will save a lot of money down the line – and preventive care also requires people employed to do the work. I know, too, that healthcare is driven, not by low costs or ego satisfaction, but by individual and immediate need; and so simply insisting on paying less isn’t really going to be an effective means of controlling demand. Indeed, because there are so much to be gained later from preventive care now, I think we need to question whether we want to simply reduce demand by reducing payment, or redirect demand by restructuring payment and actually increasing payment for some things.

One way or another, the numbers (albeit preliminary) indicate that healthcare is a sector of the market that is creating jobs, good jobs, in an economy that needs to put people to work. For all the criticism of the Affordable Care Act, this hardly seems the time to cut the payments, including Medicare and Medicaid, that will undermine that sector and all the jobs it includes now, and can add in the future.

What We Can Do With Collaboration - And Not Competition

2011-08-02T23:06:00.000-05:00

Some time past I wrote about health care and the market. I noted especially that when choices are negotiated, it isn’t patients who really do the negotiating. Instead, hospitals, physicians, and insurers negotiate with one another to determine appropriate exchanges of services, reimbursement, and lives – which is to say, us as patients.

So, what would happen if the three parties got together and became partners? Yesterday the Los Angeles Times reported on just such an event. Three major players – an insurer, a hospital system, and a large medical practice – collaborated, and in the first year attained some remarkable results: “The collaboration among Blue Shield of California, Catholic Healthcare West and Hill Physicians Medical Group shaved more than $20 million in costs last year and prevented an insurance rate hike for public sector workers in Northern California.” Now, these are two remarkable results. The cost savings are remarkable in and of themselves, and would allow the various organizations to save money for patients, marginally reducing fees and premiums. But just as important were the savings for both government employees and taxpayers in preventing the rate hike.

While the financial savings were significant, I was more interested in some of the clinical results. For the clinical results reported, cost savings were an important measure. However, I also they think they indicate quality care for patients.

For example, surgeries for weight loss were reduced last year by 13%. They did it by offering guidance for better choices. In essence, patients were taught preventive measures that so that fewer surgeries were required. The thing is, the same measures are likely to result in fewer cardiac issues and lower incidence of diabetes. So, the results are lower costs not only in surgeries now, but in improved health later.

Or consider that readmissions after hospital stays were reduced by 15%. The collaborators note that fewer readmissions indicate patient who were healthier at discharge. Readmissions have another consequence for hospitals. Medicare has structured their reimbursement around Diagnostic Related Groups, or DRGs. For a great many diagnoses, Medicare sets a specific reimbursement amount. If the patient costs less, the hospital makes a little more money. If the patient costs more, the hospital eats the excess expenses. So, if a patient is healthier faster, not only has the patient benefited, but the hospital gets some financial incentive. If a patient has a longer stay, the hospital loses money. The thing is, if a patient is readmitted too soon after a discharge, Medicare considers it part of the same diagnosis, and so doesn’t pay the additional expenses. And it’s not just Medicare: insurance companies also use DRGs to guide their payments, especially in managed care contracts. So, readmissions lose hospitals lots of money, and a15% reduction means the losses are a lot less. For a not-for-profit like Catholic Healthcare West, that means more money to plow back into equipment and personnel for patient care.

We might argue that there was a fourth partner involved in this. More than three quarters of the $20,000,000 saved came from the California Public Employees Retirement System (CalPERS) because Blue Shield didn’t raise insurance rates for those covered through CalPERS. However, this is no small thing: the costs of pension benefits are significant problems in many of our states. Saving money in this way saves money, or saves services, for many of us.

So, this is an example of collaboration that worked. Of course, it worked precisely because the partners stopped competing, at least in this instance, and instead worked together. They had some trust to build and some history to overcome before they could collaborate: "Our staffs had a history of combating with each other through negotiations," said John Wray, a senior vice president with Catholic Healthcare West. "We had to trust one another to make it happen. This was a very significant culture change between the organizations." They even shared some proprietary information. This was simply not your typical “market-based solution.” Note that it isn’t a government directed solution, either. At the same time, it’s not competition but collaboration, not proprietary interest but partnership, that brought these results.

Maybe, just maybe, that’s a model that others can follow, so that more of us can benefit.

My Thoughts on Fair Taxation

2011-08-01T23:02:00.000-05:00

So, I’ve recently seen once again this statement: “The top ten per cent (income) of Americans pay 55% of all taxes. Let them pay 65% instead.” The point that the author wanted to make was that increasing that to 65% would still not meaningfully address the deficit. It’s at least a different point than is usually made with such a statement. Usually, the suggestion is that the top 10% are paying more income tax than they should, that in a fair tax structure, collected taxes would somehow be more evenly distributed across all income classes.

I have found myself wondering about those statements, and similar statements I’ve seen (all with varying numbers, but with much the same point). So, I did a bit of searching, and found this paper, titled “Wealth, Income, and Power.” The author is William Domhoff of the University of California at Santa Cruz.

The article is illustrated with some very helpful tables and charts. For example, a chart on wealth distribution indicates that in 2007 households above the 90th percentile (90% of households had lower net worth) controlled 83% of financial wealth. So, one could argue that instead of paying 55% if all taxes collected, they should be responsible for 83% of taxes.

But, we don’t tax wealth. We tax income. So, let’s look at income distribution. In 2006 more than 41% of all income received in the United States was received by only 20% of those who received income. A different table from Citizens for Tax Justice indicates that this group above the 80th percentile of those receiving income received 59% of all income, and paid 64% of all taxes. Now, that seems pretty even, doesn’t it? But while it may look “equal” in some sense, it’s impact is not equally felt. Those above the 80% pay roughly 30% of their income in taxes. Those between the 60th and 80th percentiles pay about 29%, and those between the 40th and 60th percentiles pay about 25%. Those below the 40th percentile pay 20% or less. It looks progressive for a moment. But, think about how this impacts standard of living. Those above the 80th percentile receive in income $100,000 and up. Those below the 40th percentile receive in income $25,000 and less. 30% of even $100,000 ($100,000 minus $30,000 leaves $70,000) has much less impact on purchasing power and standard of living than 20% of $25,000 ($25,000 minus $5,000 leaves $20,000). $30,000 sounds like a lot of taxes; but $70,000 is still a pretty good discretionary income. $5,000 sounds like a lot less; but it represents a lot of groceries for folks who are already living pretty close to the margin.

It seem pretty clear that the reasons to tax those who have more in a greater measure than those who have less are first and foremost that they have the wealth in the first place; and second, that they have benefited much more from this economy that we share than most of us. And after all, they can afford it. The one person in America whose name is more associated with paying taxes than Grover Norquist is Henry Bloch, the “H” of H & R Block. He wrote an editorial that appeared in the Kansas City Star His closing comments were, this past Saturday.

Those of us earning more than $250,000 a year are very fortunate. We have an obligation to help our nation overcome this challenge. While I don’t look forward to paying more taxes, it must be done. And it’s a small price to pay for living in this wonderful country. Responsible change that promotes good public policy and tax fairness is to be welcomed.

So, here are a couple of ways to think about what might make for “fair” taxation. We could tax wealth, and set it up so that those who own 83% of the wealth are required to provide 83% of taxes paid (instead of 55 or 60%). Or, we could figure out how to tax so that those at the top have their purchasing power reduced as significantly as those at the bottom. See, it’s not whether those at the top pay more taxes than those at the bottom. It’s whether those at the top pay enough more taxes that their lives are proportionally affected as much as those at the bottom. That might be a truly progressive tax plan.

Back at the Cafe

2011-07-31T23:14:00.001-05:00

I have another post up at the Episcopal Cafe. It's about heat and hummingbirds and current affairs. Go over and give it a buzz.

I do want to commend to your attention Notre Dame’s Science of Generosity Initiative, to which I refer in the post. It might seem a stretch to most folks to think about studying generosity scientifically. On the other hand, there are many expressions of human behavior and human personality that we study. We study hope and optimism. So, why not study generosity? Go over and browse for a while. You'll find interesting papers to think about, and a blog that's updated regularly. I think you'll find it interesting. If you're at all like me, you'll find some of it just fun.

Costs and Effectiveness and Vaccine Policy

2011-07-20T23:08:00.000-05:00

I have written before about issues related to the costs of vaccines (for example, here and here). They are expensive to develop, and have inherent risks. At the same time, they’re not the greatest profit generators, in part because they’re used once or twice, unlike, say, cholesterol drugs that patients take regularly for years and years.

Today there was an interesting story on NPR’s All Things Considered. Titled, “Rising Costs Complicate Vaccine Guidelines,” it looks at a meeting of the Advisory Committee on Immunization Practices (ACIP). According to the ACIP web site,

The role of the ACIP is to provide advice that will lead to a reduction in the incidence of vaccine preventable diseases in the United States, and an increase in the safe use of vaccines and related biological products.

The Committee develops written recommendations for the routine administration of vaccines to children and adults in the civilian population; recommendations include age for vaccine administration, number of doses and dosing interval, and precautions and contraindications. The ACIP is the only entity in the federal government that makes such recommendations.

The NPR story focuses on a difficult place in our health care: the point where we discuss balancing cost and effectiveness. While the specific vaccine in the example is for meningitis, it offers a good examination of all those difficult questions: at what cost do we treat, and with what effect? Who makes that decision, and on what basis? Each decision has both costs and benefits, and each choice excludes other choices.

Take a few minutes and listen. It won’t give definitive answers (although it does tell us what ACIP decided in this case), but it will bring us back to important questions.

Political Thought for 7-15-11 (2)

2011-07-15T13:12:00.001-05:00

I want to propose a new definition of tax equity. When folks talk about fair taxes, some talk about the actual amount paid, or the rate at which income is taxed. Sometimes someone even talks about taxes paid as a percentage of income. I want to offer a new definition: I want to tax the wealthiest at a rate whereby their tax bill will affect their purchasing power to the same extent as it does someone living on minimum wage. Too much? I'd be satisfied if it affected their purchasing power to the same extent as it does mine! But, the true measure of equity would not be dollars paid, or tax rate, or even percentage of income, but purchasing power.

Political Thought for 7-15-11 (1)

2011-07-15T13:07:00.001-05:00

I can't imagine voting for anyone who appears to have failed American History in high school and college - who imagines, as we have recently seen, that the families of slaves were intact in any meaningful sense. I can't imagine voting for someone who doesn't remember from their class that the Gilded Age was only gilded for those who had the gelt.

A New Ethics Resource

2011-06-30T20:01:00.000-05:00

From time to time I do try to point to new resources for chaplains and others in health care, and especially, when I can, to resources in Kansas City, my back yard. In a recent conversation with my colleague, Dane Sommer, Director of Chaplaincy Services at Children’s Mercy Hospital in Kansas City, I learned of another.

Take a look at the web site of the Children’s Mercy Bioethics Center. It is a rich resource of information specifically on pediatric bioethics. There are a number of topics, each with its own page. Many have attached PowerPoint presentations, lists of references, and links to other relevant sites. There are links to information on relevant legal cases, and even a blog. Moreover, the Center is offering a Certificate Program in Pediatric Bioethics in conjunction with the University of Missouri – Kansas City.

So, take a look at the site. This is, I think, quite a resource in an important area in health care ethics.

Return to the Cafe

2011-06-22T08:52:00.000-05:00

After a bit of a break, I'm back up at the Episcopal Cafe. My latest piece is seasonal, in the Church's sense; and also not limited to one season. I hope you enjoy it. If you do (and even if you don't), I hope you'll leave a comment, whether there or here.

And, as always: while you're there, take some time to look around and read. There's interesting news there, especially focused on the Episcopal Church. There are interesting essays there on matters of faith and spirituality, and multimedia offerings. So, go to the Episcopal Cafe and look around. We think you'll like what you find.

Update on Endorsement for Episcopal Chaplains

2011-06-20T21:04:00.000-05:00

I have done my best to keep track of the process for ecclesiastical endorsement in the Episcopal Church. As I've noted, endorsement is perhaps the most common search terms that leads folks to my site. I also noted that changes have been happening at the web site of the Episcopal Church.

Well, one of those changes has been to move the form to request ecclesiastical endorsement. It is now available here. Even better, the path to reach it on the Church's web site is not only simpler, but relatively logical. I've given the direct link; but it you go the the Church's home page and click on the "Networking" tab, the link to the form is right there, on the "Networking" home page. Granted, that's more straightforward if you know that endorsement for healthcare chaplaincy has been moved from the Office of the Bishop of Federal Chaplaincies to the Mission Department. (Of course, if the search term led you to this site, you already know that.)

So, the form is readily available, and the process remains as it has been for a while now. And I can only think of a couple of steps for the Church's web experts to take to make it even simpler. One would be to have a page listing and providing links to all the forms the Church uses, or at least all those for use outside the Episcopal Church Center, and include that page in the links in the Church's "A to Z Directory." The second would be for the link in the "A to Z Directory" to "Chaplaincies" to include all chaplaincies in the Church, and not just Federal chaplaincies. I have the greatest respect for Bishop Magness and all of our Federal Chaplaincies; but other chaplaincies have resources at the Episcopal Church Center, and networks for, well, networking. Making those directly accessible from the "A to Z Directory would simplify the process for a lot of folks. Granted, it might mean fewer folks came here for this information; but I'd be willing to accept the pain.

So, if you're here to learn about endorsement for healthcare ministries in the Episcopal Church, the information is available. I'm happy to help, and thanks for stopping by.

More on Martyrs of Joplin

2011-06-19T15:04:00.000-05:00

I have written before of those who served at St. John's Hospital in Joplin, Missouri, when the tornado hit. Today in the Kansas City Star is a new story, based on interviews with staff, patients, and visitors in the hospital who experienced the tornado and its destruction. It's a powerful story, if a tough read for those of us who have even the smallest clue what they faced.

In the title I have made reference to the "Martyrs of Joplin." That thought occurred to me as someone who regularly remembers the Martyrs of Memphis, clergy and lay ministers from a variety of faith traditions who stayed in Memphis during years of yellow fever epidemics. While it is true that we remember by name those who died in the process of giving health care, they were martyrs well before they died. Remember that "martyr" is based on the Greek word that means "witness," one who gives testimony. We remember by name some who died; but they were witnessing in their living, in their caring, and it was only capped by death.

So, I think, we can remember those who gave care in Joplin for the care they gave, whether or not they died in the process. And while I describe those in the hospital as "Martyrs of Joplin," I haven't called them "the Martyrs of Joplin;" because I'm aware that many gave care and provided safety all around Joplin and surrounding towns, and not just at St. John's.

But, as a hospital chaplain I am particularly struck - not to say terrified! - by the experience of those at St. John's. So, take some time to read, and as you read remember all the Martyrs of Joplin: those who care for and protected others, most at risk and some at the cost of their own lives. Whether they intended it or not, they have demonstrated the best that one human can do for another: laying down one's life.

Blogging the CPE Experience: Summer, 2011

2011-06-15T22:35:00.001-05:00

Once again, I’ve taken a little time to find blogs from students in CPE programs this summer. It is a time of great investment, great stress, and, hopefully, of great learning about self and profession and self as professional. To date, these are the blogs I have found for this summer:

Inner Life, Radiant Light

Father Mark’s Musings

Confessions of Middle Aged Seminary Student

God on the Road

Jon’s Blog

Gathering Hope

Taking a Break from Civilization as We Know It

And, as always, I can commend the blog of abayye, a rabbi and CPE supervisor in New York.

As I find further blog sites writing about the CPE experience, I'll add them.

One further note: a number of CPE centers accredited by the College of Pastoral Supervision and Psychotherapy (CPSP) have made good use of blogs to provide information about their programs and about chaplaincy resources. There are also blogs among the various web sites of CPE centers accredited by the Association for Clinical Pastoral Education (ACPE), though I don't find as many. If you're looking for information about educational programs, these can be helpful. I'm more interested in connecting with the experiences of individual students in the process of CPE; but I did want to acknowledge that these blogs were also available.

So, take a look at the experiences of these students; and, as you feel moved, offer encouragement. CPE is, if nothing else, emotionally tumultuous. These folks will, I think, appreciate all the support they can get.

Social Issues Thought for 6.14.11

2011-06-14T09:27:00.000-05:00

We are ramping up already toward the 2012 election season. So, let's think about one phrase we'll hear again and again:

"You can't solve a problem just by throwing money at it."

Perhaps; but you can do a blessed lot more than just by throwing rhetoric at it.

Questions on Jobs

2011-05-30T22:07:00.000-05:00

While it's not the only topic in current politics or economics, we still talk about the importance of increasing employment. Basically, we want folks to be working. One of the statements we hear often is that one new job stimulates twelve new jobs. I don't know that that's true; and I've found a web page that's more specific and circumspect. However, it seems well established that each new job does generate additional jobs, by creating additional demand as the new worker seeks to fill his or her needs or wants. (And perhaps over time that will add up to twelve, if each new job stimulates another new job....)

So, based on that premise, I have three questions:

FIrst, isn't that as true of government funded jobs, whether employment by government or by contractors (like, say, adding new employees on road crews spending highway funds) as of any other source of funding? If not, why not?

Second, while political pundits talk about "the Governments money" and "our money," since we live in a government of, by, and for the people, and since we all pay taxes, isn't "the Government's money" really all "our money?" If not, why not?

Third, then, why shouldn't we encourage our Government to spend our money to generate jobs in the economy, instead of waiting for corporations, whose purpose is to make a profit for the benefit first and foremost of shareholders, to see the increased demand that will make it reasonable for them to add jobs? Indeed, isn't in the best interest of those corporations for our Government to spend our money to create jobs, so as to increase the demand to the point where it is reasonable for corporations to increase jobs? If not, why not?

Talk among yourselves.

Standing Before the Whirlwind

2011-05-26T22:58:00.000-05:00

When the tornado hit Joplin, Missouri, one of the first impressions many of us had was the image in the sunrise of the battered structure of St. John's Regional Medical Center. As a hospital chaplain, the image of the hospital, its windows shattered and dark, was immediately arresting. I had no idea what folks there had experienced, but I had some idea what it might have meant in my hospital.

Today, we had an opportunity to learn about what happened there. This story was broadcast on KCUR, our local NPR station, and later picked up by other stations. It gives a sense, however limited, of what employees experienced during the tornado.

We need to appreciate what the staff of St. John's Regional Medical Center accomplished. In the entire hospital, that took a direct hit from an EF-5 tornado, only six persons died - five patients who were already at high risk, and one visitor. There were certainly many injuries, but this was still a major accomplishment. It speaks to the dedication of the staff, and of the quality of the hospital's plan for disasters, and of the training that staff maintained to be prepared.

All of us in hospitals train for disasters. No, perhaps no training could be "adequate" for an event of this magnitude; but we can only imagine how much more serious the outcome could have been without it. About two hours north of Joplin, and a few days later, we also had a tornado warning and implemented our plan. Blessedly, as the storm crossed the metropolitan area, there was little damage, few injuries, and no deaths. My hospital was unaffected. Nonetheless, we followed our plan, moving each person, inpatients, outpatients, families, vendors, and staff to the safest area possible; and we waited together until all was clear. We were not challenged as they were in Joplin, and still we were comforted that we had trained for this event and had some idea what to do.

The story of Joplin speaks of acts of determination and courage among the hospital staff. In one sense, I applaud their heroism. In another, I want to recognize that they were simply ordinary people, performing well under extraordinary circumstances. I have faith that the folks I work with would do as well. It's not because they're somehow unusual. It is, rather, that I know them and trust that they would also come through.

I want to thank God for the people of St. John's Regional Medical Center, who came through in the face of unimaginable natural forces. And I would pray that neither they (nor, for that matter, any of the rest of us) are ever challenged that way again.

Let Our "Yes" Be "Yes," and Our "No" Be "No" - and Our "Wait a Bit"....

2011-05-25T10:35:00.000-05:00

We have had some interesting discussions lately about the Anglican Communion Covenant. Now, when I say “we,” I’m referring to the relatively narrow world in which I write and read. So, I don’t want to claim too much about the authority of those I read and write with. I do want to claim that the discussions have been interesting.

We’ve been discussing widely among Anglicans the meaning and import of the Anglican Communion Covenant, and among Episcopalians what action we in the Episcopal Church should take. We have noted with interest what others have done or are doing. The Church of England is in process. General Synod sent it to the various dioceses to express their opinion; and will act at the next meeting after those opinions have been received. Some other churches have acted. Notably recently that Southeast Asia has “acceded to” the Covenant; while Ireland has “subscribed” the Covenant; and both with what we might call a “signing statement.

I will admit that those choices were interesting. And being the wonky soul that I am, I went to the Compact Edition of the Oxford English Dictionary (1971):

Adopt (the word in the Covenant text itself): To choose for oneself

Definition 1: gen to take (any one) voluntarily into any relationship (as heir, son, father, friend, citizen, etc.) which he did not previously occupy.
Definition 4: To take up (a practice, method, word, or idea) from some one else and use it as one’s own; to embrace, espouse.

Accede: To come to a place, state, or diginity; to come into an opinion, to agree

Definition 3: To join oneself, become a party, give one’s adhesion; hence, to assent, agree to.

Subscribe:

Definition 1: To write (one’s name or mark) on, orig. at the bottom of, a document, esp. as a witness or consenting party; to sign (one’s name) to. Now rare.
Definition 3: To sign one’s name to; to signify assent or adhesion to, by signing one’s name; to attest by signing.
Definition 4: To give one’s assent or adhesion to; to countenance, support, favour, sanction, concur in.
Definition 7: To give one’s assent to a statement, opinion, proposal, scheme, or the like; to express one’s agreement, concurrence, or acquiescence.

Now, perhaps the differences among these words aren’t so great; and yet these words were deliberately and carefully chosen. I find “accession” especially interesting, in that we have been discussing “accession” a lot these last few years in the Episcopal Church. A diocese “accedes” to the Constitution and Canons of the Episcopal Church; that is, acknowledges and accepts the normative authority of the Constitution and Canons, and recognizes its own documents and actions as subsidiary. It suggests that Southeast Asia accepts the Covenant as a constitutional document, to which provincial actions would be subject.

Of course, the Irish “signing statement” said just the opposite, asserting as normative the provincial Constitution and Canons. Rather, they chose to “subscribe,” which suggests more an agreement among separate but equal participants.

And that, of course, was different from the “adoption” called for in the document itself. “Adoption” says more about a change in identity, establishment of a new relationship, and in this case participation in a new body: churches within the Anglican Communion that are signatories of the Anglican Covenant (which, at this point, within the Covenant text are indeed separate if overlapping groups).

We have also seen something different, if only in a preliminary step. While this was not their definitive action, the church in Aotearoa, New Zealand, and Polynesia voted on each Section of the Covenant separately. Sections 1, 2, and 3 were passed, and Section 4 wasn’t.

So, what is the Episcopal Church to do? Several of us who speak to the issue have some stake in the conversation, not just because we are Anglicans and Episcopalians, but because each has some small part in the governance of the Episcopal Church.

Mark Harris, a past Deputy to General Convention (and perhaps again), and a member of the Executive Council, has expressed at “Preludium” the opinion that we must say no. This is based in part on the thought that the idea of a Covenant is un-Anglican, and in part that the Covenant text establishes a new centralized structure more like, if not just like, Roman ecclesiology; but mostly because it appears the point of the exercise is to exclude those who most think have stepped too far in embracing changing understandings of who we are as human beings living in the world and before God – and in the first instance, the Episcopal Church and (probably) the Anglican Church of Canada. To do this, the Covenant so changes the relationships among Anglican churches and to the Instruments of Communion as to subvert and divide the Anglican Communion in service of a new Anglican Church. While this is not explicit in the Covenant text (and perhaps not inherent in it), Mark and colleagues simply do not trust those others who will embrace the Covenant not to take these next steps.

Tobias Haller, a Deputy to General Convention, has argued at “In a Godward Direction” that there is a rational reason to sign the Covenant. As he sees it, the descriptions in the Covenant text of the roles and authority of the four Instruments of Communion, as well as of the renamed Standing Committee are not new, and in fact reflect accurately their current extant roles and authority. The Covenant text also incorporates means for revision of the Covenant itself. So, he argues that we need to pursue appropriate revision of the Covenant; and to do that we have to be signatories. We might say he trusts the text of the Covenant itself, and some responsiveness of other signatories sufficient that they will engage with us immediately in a process of amendment, as the Bill of Rights is not part of the U.S. Constitution as passed, but were instead the first amendments to it. He also trusts that some Anglican churches, and specifically some that we could expect to militantly resist efforts at amendment, will follow through on opinions already expressed saying that they can’t sign.

And I, also a Deputy to General Convention, have been reading and responding on both blogs (and especially to Tobias). I have a concern that for signatories of the Covenant, the processes of Section 4 will eliminate reception, Indaba discussions, and mediated conversations (from Section 3 of the Covenant text). As I wrote,

Perhaps my greatest concern is that this will indeed stifle adhocracy (sic) - when in a world more and more "networked" than institutional, adhocracy will be useful more often than it will be painful. "If your only tool is a hammer, every problem begins to look like a nail;" and while we can imagine that there will be other means for addressing differences, the temptation of possible resolution will pull more differences, more "problems," under the "hammer" of the Covenant's Section 4.

Our understanding of engagement and gradual reception seems largely gone from our discussions of how ideas are shared and embraced (or not) among the churches of the Communion. I hesitate to sign on to the Covenant, in fear that it will only "drive another nail into the coffin."

Perhaps we might say that I don’t trust the process – either the specific processes suggested in the Covenant text, or the intentions of all those who might be in the signatory group. With that in mind, I have noted that there is no deadline by which we must sign. We could at the next General Convention express our commitment to Communion, and to the existing Communion structures, and to continuing the Covenant process without being ready yet to commit. We could continue study and reflection until 2015. In the meantime, we would have more information. We would know who else had signed on. We would know what intentions had been expressed by signatories and by some of the Instruments of Communion in understanding the relationship between the churches of the Anglican Communion and the signatory churches of the Anglican Covenant. We would be embracing some tension in delaying, but we would be making a more informed decision.

And there are other possibilities. We could adopt the Covenant with our own “signing statement.” We could act something like Aotearoa, New Zealand, and Polynesia, considering each Section separately and announcing what we have adopted, and what we haven’t. We might adopt, and also pass a resolution describing the amendment(s) that we intend to pursue.

We also need to acknowledge that each of these choices has some risk. If we choose not to sign, then among those who do sign there may well be enough still who wish to redefine participation in the Communion as participation in the Covenant so as to make that certain. Indeed, some who have said they couldn’t sign might just change their minds, magnifying the possibility. If we do sign with the intent to amend, there may still be enough among the signatories who don’t want amendment to prevent it; and so we’ll find ourselves committed in relationships that can inhibit us in living out the Gospel as we understand it in our own time and place. First and foremost, we’d be embracing further tension at home, and confusion and frustration among Anglican colleagues abroad. We would continue to be challenged as to whether we’re serious about communion. Moreover, if we delay for more reflection, time may still hurt us. While I think it unlikely that significant change could be accomplished in three years, enough change could happen to establish a trajectory we’d find it hard to turn. Even if we sought to adopt in a more controlled way, whether section by section, or by adding a “signing statement” or proposed amendments, some of these same risks would be present.

So, what are we to do? Like other Deputies, right at the moment I can’t say what I would do. That’s because the real action will be that taken in General Convention; and we don’t know yet what resolutions will be proposed, much less what will come from the appropriate legislative committee to the floor of either House. We don’t know what amendments or substitutions will be presented. So, we can’t commit to one specific vote or another, whatever we think about in all this thinking out loud (and what, after all, is a blog but thinking out loud?). I think first and foremost, we need to be conscious and informed about possible choices, and about the risk each entails. Then when it comes to a vote, we’ll be offering our best, most informed leadership.

Caught My Attention: 5.11.2011

2011-05-11T14:35:00.001-05:00

For the love of God is this, that we obey his commandments. And his commandments are not burdensome, for whatever is born of God conquers the world. And this is the victory that conquers the world, our faith. Who is it that conquers the world but the one who believes that Jesus is the Son of God? (1 John 5:3-5)

Whenever I encounter it, I find myself wondering about the "conquering the world" thing. From the way I've sometimes seen it protrayed, it's a long way from the one who said, "My kingdom is not of this world."

A Side Comment

2011-05-11T09:35:00.000-05:00

You may have noticed that I was silent for a while. Part of that was Holy Week and Easter, always a busy time. Part of that was recovery from Lent, Holy Week, and Easter - harder this year for some reason.

But, part of it was looking for something new and interesting to say. Let's face it: there are lots of folks saying interesting things about the Anglican Covenant, or about ethics, or about the Episcopal Church. I was feeling some writer's block: what did I have to say that was noteworthy?

So, I'm stepping back a bit, and taking a different focus. That's why the momentary reflections on the Office Lectionary have been happening. I'll get back to writing the essays soon. With even a few days of a different focus, I'm picking up on some news items I'd been overlooking. In the meantime, the door stays open. I'm happy when folks find interesting something I've posted here. And even if it's an old post, feel free to comment. After all, it's nice to find some of those things still relevant.

What Caught My Attention: 5.10.2011

2011-05-10T11:53:00.000-05:00

Beloved, let us love one another, because love is from God; everyone who loves is born of God and knows God. Whoever does not love does not know God, for God is love. No one has ever seen God; if we love one another, God lives in us, and his love is perfected in us.

God is love, and those who abide in love abide in God, and God abides in them. Those who say, ‘I love God’, and hate their brothers or sisters, are liars; for those who do not love a brother or sister whom they have seen, cannot love God whom they have not seen. The commandment we have from him is this: those who love God must love their brothers and sisters* also. (1 John 4:7-8; 12; 16b; 20-21)

Love brothers and sisters? Wait - all of them?

And what is the standard of love? How is love demonstrated? 1 Corintians13:1-13 comes to mind. But, let me get more explicit. Is it first about what is good, healthy, life-giving for the other? Does one rejoice, not for his or her own joy, but for the joy of the other? Or weep for the sorrow of the other? Does one sit long hours at the sickbed, or drive to appointments, or fix a meal? Does one stay for years, to the point of sitting with the dying, and mourning in the loss, to the point of losing some part of her or his identity?

That is love enough to convince me. That looks like love to me, regardless of the exact description of the relationship, of its legal standing or its social acceptability, or just how it's physically expressed. That seems to me to be love; and love is of God, for God is love.

Caught My Attention: 5.9.2011

2011-05-09T13:09:00.000-05:00

From today's lections for the Daily Office:

And by this we will know that we are from the truth and will reassure our hearts before him whenever our hearts condemn us; for God is greater than our hearts, and he knows everything. Beloved, if our hearts do not condemn us, we have boldness before God; and we receive from him whatever we ask, because we obey his commandments and do what pleases him.

And this is his commandment, that we should believe in the name of his Son Jesus Christ and love one another, just as he has commanded us. All who obey his commandments abide in him, and he abides in them. And by this we know that he abides in us, by the Spirit that he has given us. 1 John 3:19-24

So, if this is his commandment; and if all who obey it abide in Christ; and if we are comfortable with this, not condemned by our own hearts; I have to wonder just what we spend so much time fighting about....

Thought for Good Friday, 2011

2011-04-22T10:21:00.000-05:00

For you have died, and your life is hidden with Christ in God. When Christ who is yourlife is revealed, then you also will be revealed with him in glory. (Colossians 3:3-4)

May we all have a Ghastly Good Friday - that is, one moved and sustained by the Holy Ghost.

A Sheep in Wolf's Clothing: More on Being Research Informed

2011-04-20T12:03:00.000-05:00

I have written before about the importance of being a research informed chaplain. Two years ago I wrote,

Nurses, physicians, and social workers are publishing research related to spirituality. We as chaplains need to be looking at it for two reasons. First, some of it is actually useful, and we need to know about it. Second, some of it is really not good from our perspective, and we need to be responding critically to it. If those other journals started getting clear and reasoned responses from chaplains, our visibility would rise.

So, as a result, now and again I look through various nursing and medical journals for articles of interest. That’s how I ran across “Is Intercessory Prayer Valid Nursing Intervention?” by Cecily Weller Strang, MSN, RN (Journal of Christian Nursing, Vol. 28, No. 2 [April-June, 2011], pp. 92-95).

Now, before I get into the article itself, let me share my thoughts about the Journal of Christian Nursing (JCN). It is the official journal of the Nurses Christian Fellowship (NCF), and is a ministry of Inter-Varsity Christian Fellowship. Many of us will remember Inter-Varsity Christian Fellowship for its primary ministry on college campuses. This is, as we might say, a journal in which there is no deceit. There is no pretence about their editorial perspective, their target audience, or for that matter their theological perspective (there is a page describing the “Doctrinal Basis” of the NCF). I find it interesting to check out occasionally because in any one edition both my concerns may be apt. That is, there will be some articles that are useful and worth the consideration of chaplains. There will also be some articles that are explicit testimonies. I really don’t have a problem with either. The interesting articles give me something to think about. The testimonies are no worse, really, than the essays and anecdotal reports published in any other journal.

And then there are articles like “Is Intercessory Prayer Valid Nursing Intervention?” It is homiletical, but using the formal academic language of a literature survey. This is not to say that there’s anything terribly objectionable about the article, but there’s little about it that’s terribly exciting, either.

Moreover, there are points at which she seems to undermine her own point. She has a discussion on “Measuring Prayer Effects” that seeks balance. At the same time, since it’s largely in form a review of literature, she offers little interpretation. Instead, she makes an assertion and provides a citation, but with little detail about what in the source cited supports her assertion. Then, in the midst of that, she states, “Note that the use of IP [intercessory prayer] as if it were another drug or medical procedure is not appropriate.” Since she wants to argue that intercessory prayer is a definable intervention, at the very least this statement needs more explication. How is it an intervention, if different from “another drug or medical procedure?” (And, indeed, her abbreviations of IP [intercessory prayer], DIP [distant intercessory prayer], and PIP [proximal intercessory prayer] seems only to clinicalize prayer in parallel with other interventions.) Her attempt to balance this statement by following with, “Neither is it appropriate to deem IP as magical...” doesn’t really address this shortcoming.

She states, “There is precedent for studying IP in nursing care.” This would seem an apt point at which to review any specific studies. Instead, she makes several comments that assert the relevance of concern for spiritual needs in nursing practice, none of which reflect research. She does in an earlier part of the article make some reference to issues in prayer research. This could be strengthened with more explicit references to both past attempts to study prayer, and the difficulties and limitations of such studies. However, the articles cited are not clinical studies of prayer as an intervention. In this case, it would be meaningful to point to both conclusions of specific studies, whether in the earlier paragraph, or in her section on measuring the effects of prayer. (Full disclosure: as a staff chaplain I participated in such a study. You can learn about that study here. I will only say at this point that I am fully aware of important limitations in our study.)

Perhaps the question that caught my attention first was that of whether this was a “nursing intervention,” as opposed to an intervention available to nurses; that is, to what extent is it specifically a nursing function, instead of a function that many might engage in. My reaction was that the latter was true, but not the former. So, it a nursing function and not a chaplain function to manage a medication pump. By the same token, if the situation is appropriate, a chaplain might pray, or a nurse might pray, or another person might pray. If we want to see this as an intervention (and I do; but more about that in another post), it is not the specific purview of any profession. Strang notes “personal knowledge” as a “characteristic fundamental to nursing knowledge.” She goes on to say that “a nurse using personal knowledge of and offering IP to patients is a valid expression of nursing care.” If we understand this to include specifically information from the patient about the patient’s willingness and tradition, I can agree. By the same token, I think referral for a chaplain can be very important when the chaplain can bring to bear personal and professional knowledge about the patient’s tradition, and can explore with the patient an appropriate approach. (But, of course, bringing the chaplain into the discussion might appear to question whether this is an appropriate intervention for nurses to use.)

This, then, brings up a critical issue: the patient’s wishes. When I discussed this with my Best Beloved, who is, among other things, RN, BSN, CHPN, her reaction was, “Of course this is an appropriate intervention for a nurse to use, if it’s what the patient wants.” Let me state clearly that I don’t see evidence in this article that the author wants to impose anything on a patient, or to violate a patient’s tradition, dignity, or wishes. She cites several sources that she sees as offering appropriate guidance,

including applying careful listening, attempting to understand spiritual needs, employing prayer aloud with the patient only with permission, never pushing prayer or beliefs on another, and being authentic and fully present with the patient in the moment. In essence, professional use of IP entails careful respect of patients’ needs, wishes, and beliefs. As professionals desiring to offer the highest standard of care, Christian nurses should employ best practices for the use of IP in the clinical setting.

And so should non-Christian nurses, and chaplains for that matter.

So, here we have an article that pursues a specific point, that intercessory prayer with a patient can, in the right circumstances, can be an appropriate action for a nurse, even in our technological medical culture. It is a reasonable position to take, and published in a journal where it will be well received. At the same time, reading it as a chaplain, I wish she had done what she set out to do more thoroughly. She want to bring to bear her best self in her nursing care, and to do so in a way that supports and does not harm patients. Unfortunately, her effort to support her argument from the professional literature is not as successful.

Part of what this shows reflects my own contention. I think had she been more familiar with the professional literature of pastoral care she would have found better support and interesting reflection for her article. Had she been familiar, for example, with the work of Larry Vandecreek or with articles published in the Journal of Pastoral Care and Counseling, she would have had input from professionals for whom prayer is an intervention for which, while not limited to chaplains, chaplains have specific training.

So, as I said at the beginning, I think we need to read the publications of other professions; and I think other professionals need to read ours. It will offer all of us critique from a variety of perspectives; and I think that those varying perspectives will improve, not only the knowledge we can all share, but the care of patients, to which we’re all committed.

A View of Things at the Episcopal Cafe

2011-04-14T10:26:00.001-05:00

My newest piece is up at the Episcopal Cafe. Let's just say it's a matter of perspective. Take a look, and feel free to comment, either there, or here.

And as always I want to encourage you to read more than just my stuff at the Cafe. I'm in good company there, with folks who put up good work. Share with us in that, and let us know what you think, too.

Words Have Meaning

2011-04-08T23:27:00.000-05:00

Insurance companies are in business to make a profit. They do not, by and large, exist primarily to pay claims. Yes, there are mutual companies and co-ops that have a closer relationship with clients because clients are members and owners. However, commercial insurance companies make money by investing premiums, not by paying claims - a financial industry, and not a service industry.

If you have any questions about that, you need to understand the phrase "medical loss ratios." You can find a technical definition here (scroll down to it), but essentially it’s the portion of premiums received that an insurer pays out for medical care; and the rest is presumed to be administrative expenses. So, what they pay out for claims isn’t something they’re happy about. It’s a “loss.” If they were oriented to service and not to financial gain, wouldn’t it be something like “customer service ratios;” or perhaps “care provision ratios?” Businesses committed to serving would, I think, want to take credit for service to customers, or for care provided. No business wants to take a loss.

Now, commercial insurance is a for-profit industry. Making a profit isn’t a crime. By and large, it isn’t a sin (well, that’s perhaps the subject for a longer discussion, but for the moment stay with me). So, if the proportion of premiums paid out was 100%, there would be no profit. More to the point, there certainly are appropriate administrative expenses. Without decent administration, claims wouldn’t get paid; and some payments would be wrong or inappropriate.

There’s also room for discussion about what constitutes “medical care.” Some things are obvious: reimbursements for a physician visit, or nursing care in the hospital, or for the antibiotic prescription. Others are clearly not, or at least are clearly not covered in the contract, such as over the counter cough drops or a massage. Sure, they help us feel better, but we don’t expect them to be covered by insurance. But, what about alternative care, like homeopathy; or cosmetic care, like some surgeries or weight loss plans? Some folks find them useful. Some of the procedures will benefit a small group of patients, but for most they will be matters of vanity. So, should insurers pay for them? Should they pay for the few who will benefit, while not paying for those for whom the procedures are strictly cosmetic? The devil can be in the details, and details matter, if we want our insurers to be good stewards (which is to say, if we want our premiums to be used as well as possible, and stay as low as possible).

This is a particularly hot topic, because the Affordable Care Act now sets requirements for administrative costs and medical loss ratios. That is, there are requirements that insurers pay at least 80% of premiums received for medical care. (You can get details here; and you can learn a bit about a recent study on the subject here.). So, beginning this year there are limits on what they can spend on administrative costs; and beginning next year insurers have to report annually what their expenses are. The law also allows the Department of Health and Human Services to grant waivers to states to allow more time for the insurers they oversee to meet the standard. Health insurance plans are overseen by each state, and some states already have limits on administrative costs. However, the Affordable Care Act mandates consistency across the country. So, insurers won’t benefit by moving from one state to another, or canceling coverage in a state, to seek a better ratio of expenses to “medical loss.”

But, I still think it clarifies things to know they talk about “medical loss ratios.” Folks, we pay good money for health insurance, and to cover those who can’t get insurance – in premiums, taxes, and the incremental price increases to cover unreimbursed care. No, it’s not a crime to make a profit, nor (usually) even a sin. However, while they’re focused on profits, we, the customers and clients, are focused on being served. It seems pretty reasonable to me that we as a society set some standards about how much of our money gets spent on service, even if it means a little less profit for the company.

The Latest on Endorsement for Episcopal Healthcare Chaplains

2011-04-04T10:17:00.000-05:00

"Becoming an Episcopal chaplain," and seeking "endorsement for healthcare ministries" in the Episcopal Church, are perhaps the two most common search strings that bring folks to this blog; and, of course, the two questions overlap. Some changes are in the works, and I wanted to make sure folks who come here will be up to date.

Margie Tuttle, the Immediate Past President of AEHC, has had a conversation with Terry Foster at the Episcopal Church Center. Terry is the person who processes applications for endorsement. The Episcopal Church web site is being redesigned once again. Therefore, the online application form for endorsement for healthcare chaplaincy may not be readily available. Terry asked that we spread the word that anyone interested in endorsement call or e-mail her directly at (212) 716-6068 or e-mail her at tfoster@episcopalchurch.org. I would presume she could also be reached through the Episcopal Church Center's 800 number: (800) 334-7626 , ext. 6068. If you're thinking about endorsement, or know someone who is, please pass this on.

A Nursing Study on Touch - And What We Might Learn

2011-03-27T19:52:00.000-05:00

When I’ve reflected on what it means to be “research-informed,” I have observed that we need to read research in the journals of other professions. With that in mind, last week I did a bit of bouncing through journals to see what I could find of interest. Because I believe clergy function more like nurses than like physicians, in this case I went looking in nursing journals. And I found several articles that I found interesting.

One of those was titled “How Should I Touch You?: A Qualitative Study of Attitudes on Intimate Touch in Nursing Care.” (AJN, March 2011: Vol. 111, No. 3, pp. 24-31) Now, I will admit that I was intrigued by the title before I read the subtitle. Chaplains are almost never involved in “intimate care” as specified by the authors (although I can’t say never: patients have asked chaplains to stay through care when they would normally have excused themselves), much less in “intimate touch.” However, there are still themes that I think are worth noting for any physical touch during care, even when it’s not “intimate care.”

For the study, the researchers gathered three focus groups, for a total of 24 participants (12 male and 12 female). Potential participants who were nurses or who had been nurses or nursing students were excluded. Participants were gathered from ROTC students from a Catholic university; parishioners from a Catholic parish; and from a Protestant congregation (the congregations where the researchers worship). Discussions were guided through a series of questions:

What do you think about, or how does it make you feel when you think about, a nurse having to touch you in private areas of your body in order to take care of you?

If a nurse had to help you take a bath, what things might a nurse do that would make you anxious?

Let’s say you are confined to bed. After using a bedpan, you realize you accidentally soiled your pajamas and bedsheets, and the nurse has to clean you up. What things can the nurse do to help you maintain your dignity?

Let’s pretend you have been in a terrible accident and have to have other people do everything for you. John is your nurse today, and he has dome to do your personal hygiene. What should John do to show you that he is professional and respectful?

How should John touch you?

Does anyone have a different thought about this?

Is there anything else we should teach nursing students about touch?

The facilitator or recorder will summarize key points and comments from the discussion to validate accuracy and provide an opportunity for clarification.

As in any focus group, these questions provided context and framework, and generated other questions and comments. Each group lasted 60 to 90 minutes, and was both taped and transcribed.

From the groups, recordings, and notes, the researchers identified four themes. First, “Participants in each focus group said communication was of the utmost importance before intimate touch could take place…. Also, participants said that communication should convey professionalism and respect.” They wanted some sense of rapport, and not a clinical distance, and even “welcomed some self-disclosure from nurses….”

A second theme was the desire of participants for choice. “Participants said they wanted to be involved in deciding whether intimate touch was necessary and whether there were alternatives.”

A third theme was that gender was an issue to be addressed: participants would want to be asked. Having been a patient who had received care from a nurse of the opposite sex could make a difference in the concern if the experience had been professional and supportive; but not always. In addition, having a chaperone addressed one issue and raised another. Participants felt they would want rapport with and involvement by the chaperone in addition to the caregiver.

Finally, the manner in which the nurse approached and touched the patient were also important. Participants expressed a desire that the nurse appear confident and professional. The nurse should respect the patient’s privacy as much as possible, including closing doors whenever possible, and not just curtains. Finally, the nurses touch should also be confident and professional, neither lingering nor rapid and rough.

For the chaplain, presence for, much less participation in, intimate care will be far and away the exception. At the same time, our interactions are emotionally intimate, and we can apply these same principles in some sense. Even though between short hospital stays and the priority of treatments and other activities our time with patients may feel quite limited, it is still important for us to communicate clearly our interest in the patient as person, and our role and reason for visiting. There is power in asking the patient’s permission, not only to touch, but also to be present. The comments about the chaperone may apply, too, in educational settings where a student may shadow an experienced chaplain, or a supervisor may accompany a student on a visit. Both persons present should engage the patient, while being clear between themselves who is responsible for care.

It is also important for chaplains to take seriously issues not only of gender but also of other expressions of diversity in encountering patients. While we as professionals are called to provide care across the boundaries of our differences, our patients are not required to accept it. While we may chafe if we’re rejected over issues of gender, race, creed, etc, we are still called to respect the individuality of the patient as best we can. At least, by accepting the patient’s refusal with good grace, we allow the patient to exercise some control.

At the same time, we, too, are called to be sensitive about how we touch, both physically and metaphorically. Even to take a hand or to touch a shoulder for prayer requires the patient’s consent. We might accept it implicitly if the patient reaches for the chaplain; but we do well to confirm consent in all circumstances. By the same token, we need the patient’s consent for intimacy regarding the patient’s history and feelings. There is a point to bringing a limited agenda to the chaplain’s approach to the patient; and the short-term focused psychotherapy appears to demonstrate benefits that we can parallel. However, the patient in the bed is not the client on the couch, present largely at his or her own request. It is important that we present ourselves professionally and confidently. It is also important that we appreciate the patient’s sense of timing. We are called to approach the patient clearly (and so not be “too slow”), while also accepting the patient’s sense of readiness (and so not be “too fast or too rough”). There are times and settings where direct confrontation is appropriate, but they are relatively specific. In general, a sense of the patient’s readiness and timing is an appropriate part of spiritual assessment.

I expect many of my readers will respond to all this with, “Yes; and?” It seems to me that this is information we know, information we have intuited from our own experiences and our concern and respect for each patient’s individual dignity. However, the authors of the study were surprised to find that this topic had never been studied and published. While there is value to our inferences, it is important to test them. The researchers have studied the topic, and so questioned the inferences among nurses. We can benefit from their work as well, by respecting what they learn in the process for their own profession, and by considering what we might also learn in the process.

Nice News About Another Episcopal Chaplain

2011-03-26T21:57:00.000-05:00

Another note from this year’s gathering of chaplains in APC and especially in AEHC this year. One of our own has been honored. Carolynne Fairweather, DMin and Board Certified Chaplain, and member of AEHC, was recognized as one of two recipients nationally of the APC Outstanding Local Leadership Award. According to the APC web site,

The Outstanding Local Leadership Award is given to a member in good standing who has exhibited outstanding dedication to and promotion of APC through active involvement and initiative at the local level, including substate, state, or multistate levels.

Among the comments reflected in her biography for the award was this quotation: “Her enthusiasm and gift for hospitality is both amazing and contagious. You feel truly welcomed and you want to become involved when you are around her.”

So, for Carolynne, blessings and congratulations!

Raising Up One of Our Own

2011-03-25T23:08:00.000-05:00

One of the joys of gathering with colleagues is discovering wonderful things they have done. I have one of those to announce. My colleague, Episcopal priest and chaplain and AEHC member the Rev. Dr. Hiltrude Nusser-Telfer has written a book, and it's now available for purchase. The title is Outcomes of Faith During Hospitalization: A Case Study Method. It describes her own steps in reviewing cases, and offers a number of cases to illustrate. It is available from Author House in paperback and as an ebook; and also from Amazon and Barnes and Noble.

Case studies, both in the form of verbatims, and in other formats have been essential parts of clinical learning and professional development for chaplains. We need to share the stories, and also how we analyze and learn from them. Chaplain Nusser-Telfer is sharing her stories with us and offering herself. It's one more opportunity to learn from one another's experience.

A New Voice

2011-03-24T23:50:00.000-05:00

You may have noticed that I have a list of blogs whose authors write about chaplaincy and issues important to chaplains. Well, I've added a new one to the list. Martha Jacobs, a Board Certified Chaplain and valued colleague will now be blogging at the Huffington Post. Since HuffPo is one of the most active news aggregator sites on the web, this should bring a lot of attention to issues of pastoral care, and bring a well reasoned perspective to issues of health care. Go take a look: Martha's well worth knowing.

An Important Issue - or At Least I Think It May Be

2011-03-21T21:33:00.000-05:00

I suppose it’s a case of what did we know and when did we know it. A story came to my attention. It’s online at Mother Jones, and it’s titled, “Death By a Single GOP Cut?” According to the author, Suzy Khimm,

The House GOP's 2011 budget would chop $156 million from the Centers for Disease Control's funding for immunization and respiratory diseases. The GOP reductions are likely to hit the CDC's support for state and local immunization programs, the agency's ability to evaluate which vaccines are working, and its work to educate the public about recommended vaccines for children, teenagers, and other susceptible populations.

So, the cuts would result in less money for vaccinations through public health providers. That means fewer children vaccinated, and more children at risk for avoidable infectious diseases.

We have recently seen outbreaks of whooping cough and measles. We know the risk is real enough between those who can’t take vaccinations and those whose parents have been so misinformed as to withhold vaccinations. Reducing vaccinations as a result of reducing federal dollars would only exacerbate the problem.

Now, as liberal as I am, and as sympathetic in general to the editorial perspective of Mother Jones, I’d like more documentation. So far, no one else has picked up this story, at least as far as a search in Google News will show. I did look at the site of the American Public Health Association (APHA), and found a press release: “APHA Strongly Urges U.S. House to Oppose Deep Cuts to Core Public Health Initiatives.” Unfortunately, that single sentence is all that’s available on the web site.

So, we have one news site referring to a possible risk to a very important public health function (and, no, Huffington Post is not a second reference, because all HuffPo does is cite the Mother Jones article), but without specifics (like the name or number of the bill, and – even better – the paragraph number and a link, so that we could read for ourselves). We have a statement from a reputable professional organization, but it’s very generic; and while it might well include the specific program of concern, it doesn’t say so.

I certainly want to know more. I’m going to pay attention. On the other hand, I wouldn’t put such a short sighted decision beyond the imaginations of someone in Congress, I find it hard to imagine that most members are so badly informed as to allow this to happen. So, with all due respect to Ms. Khimm, I’m going to watch for this, but I’m not going to get upset until I hear more.

Let's Go Through It One More Time - at the Episcopal Cafe

2011-03-17T09:57:00.000-05:00

I have something up again at Episcopal Cafe. It is a reflection on music and repentance and Lent. Feel free to let me know what you think, whether at the Cafe or here.

And once again while you're at the Cafe, take some time to look around. There are many good essays and reflections to read there, and good information in issues important to Episcopalians and other Anglicans. As one of the contributors, we're always happy to have folks read, mark, and learn - and then comment, so that we hear what others are thinking.

How? How Else?

2011-03-09T10:43:00.001-06:00

How is it that we find these words to be words of hope, and not of fear:

Remember that you are dust, and to dust you shall return.

How is it that we find these words to be words of promise, and not of despair:

Remember that you are dust, and to dust you shall return.

How is it that we find these words to be words restoration and return, and not of loss and desolation:

Remember that you are dust, and to dust you shall return.

How, save by trusting in Christ and in the grace of God?

The Case in Montana

2011-03-07T23:49:00.000-06:00

A while ago I shared my appreciation for psychiatrists and psychologists, and the appreciation I’ve found among many for patients’ spiritual concerns. If you recall (or as you’ll discover if you read the earlier post), that was illustrated by the story of the psychiatrists who regularly consulted me when a foreign-trained medical resident heard a patient say, “If it’s my time to die, if God calls me, I’m ready to go,” and identified it as “suicidal ideation.”

I thought of that story again when I read about a court case in Missoula, Montana (you can read about it here and here). A woman, identified in court documents as L.K., was diagnosed with Stage I cervical cancer. She has hesitated to have a hysterectomy. Reportedly, she made this decision so far in part because she might want to have a child (something a physician has stated is unlikely but possible), and in part for “religious reasons.”

Her “religious reasons” were a matter of concern for one of her physicians and one of her nurses, who between the two of them sent three letters last fall to the Missoula County attorney’s office. The point of the letters was to question, based on her “religious reasons,” whether she was competent to make the decision regarding surgery and a condition that would eventually be fatal if left untreated. A medical guardian was appointed, who signed a consent for the hysterectomy. The surgery was scheduled for last Thursday, but has been postponed by the State Supreme Court to allow an appeal by a public defender.

In a hearing last week, a psychiatrist stated that the patient had “religious delusions,” including that “God had healed her.” These delusions prevented her from making the appropriate decision to accept the surgery. The patient, on the other hand, said she did understand her condition and her risk. She simply wanted to make her own decision on her own schedule. Her public defender said she is not delusional, but simply very religious, and that forcing this surgery would harm her religious freedom, her physical integrity, and her dignity.

Now, let me say that it is entirely possible that a person might be delusional with religious ideation. It is possible that is the case with this woman. However, without actually hearing the conversations, I couldn’t say for myself which I thought was the case. And while I do have respect for psychiatrists and psychologists, and find that the great majority of them have respect for patients’ religious concerns, there are exceptions. There are still those who feel that any religious thoughts are by definition dysfunctional. Again, without actually hearing the conversations, I hesitate to express an opinion.

There is, though, another point from which to consider this. I have observed that autonomy has become the driving moral principle in health care decisions these days. This case has in tension the patient’s autonomy with the physicians’ concern for the patient’s best interest (Beneficence). Now, if and to the extent that this woman is delusional, she may be limited in understanding her own best interest (and I say “to the extent” because decisional capacity isn’t really all or nothing); but if and to the extent that she is not delusional, she has the right to make this decision, even if she ends up dying for it.

That’s really the hard point of the principle of Autonomy for many health care providers. If we are to allow patients to make their own decisions, we have to respect their right to make even decisions we thing are wrong. Yeah, we might think a particular decision is wrong, or even crazy; but that doesn’t make the patient crazy in the clinical sense.

We can certainly hope that the judge will give the appeal careful and thorough consideration. L.K. certainly needs for the review to be thorough, but so do the rest of us. If it appears that a patient has been declared incompetent only because the patient refuses a treatment, even a treatment that may be life-saving, there is the risk that a court decision may result in loss of rights for many of us.

Thoughts for the Last Sunday After Epiphany (A)

2011-03-05T22:49:00.002-06:00

As they were coming down the mountain, Jesus ordered them, "Tell no one about the vision until after the Son of Man has been raised from the dead."

Why in heaven’s name would Jesus do that? They’d just had the spiritual experience of their lives. They had just seen God’s glory reflected in their rabbi. In light of Peter’s confession that Jesus was the Messiah, it was as reasonable as they could imagine – if one could describe as reasonable an experience they could not have imagined before it actually happened. This was, in a way, the ultimate confirmation of the time they had spent with Jesus. They had been with him almost three years. They had left it all to follow Jesus, friends and family and good careers, and now they had the confirming experience. God had show unmistakably, unequivocally, that his favor shone on Jesus. There he was, in light they could hardly bear, flanked by the heroes of their faith, Moses and Elijah. And after all that, Jesus says, "Tell no one about the vision until after the Son of Man has been raised from the dead." How could he do that?

Perhaps it was to prevent them becoming, as folks say, “too heavenly minded to be any earthly good.” If they spent all their time looking in awe at Jesus, they might well miss all that went on around him – and from this point, there’s still a lot to see around Jesus.

Perhaps it was because of the distance they still had to travel. The journey from the foot of the Mount of the Transfiguration leads up to Jerusalem – and to the cross. The story would not end, and could not be understood, if they never left the mountain, even in their own minds.

Perhaps it was because they hadn’t yet understood their vocations, vocations that would not actually be set until after the resurrection. Indeed, as the story could not be understood if they never left the mountain, neither could their ministries take form if they never left the mountain.

One way or another, they had much yet to see, far yet to go, and a lot yet to learn. For all the excitement they had experienced – and for all of the joy found in simply adoration – there was more to experience; and they would never see it if they stayed, even in their own minds, up on the mountain.

Icing on the Cake

2011-03-05T19:59:00.000-06:00

It has been a fun day here in West Missouri. Today by God's grace and with God's people gathered, Martin Scott Field was ordained the eighth Bishop of West Missouri. It was, or course, quite a service. The ordination of a bishop is not something we experience that often (okay, well, bishops do; but not most of us) because our diocesan bishops are, by and large, pretty healthy and serve for a while. So, it is a rare and exciting event. But, then, we do grand ceremony like nobody else.

For me personally, too, it was a great day, at least as an Episcopal blogger. George Clifford, who blogs at Ethical Musings, and who is with me a regular contributor at the Episcopal Cafe, was the preacher. He knew Bishop Field when both were Navy Chaplains together. Indeed, I met George because of his Navy chaplaincy. He and I worked in several General Conventions tracking resolutions for Bishop George Packard, then Bishop of Federal Chaplaincies (which is the current title of the office).

And after the service, I heard a voice: "Aren't you Marshall?" Lisa Fox of My Manner of Life and Maria Evans of Kirkepiscatoid had come to Kansas City for the celebration. Both are in Missouri (although in the other diocese), and so were able to make the trip for the day. As happens with bloggers, we've read each other's stuff. We just haven't had the chance to meet.

That's the way it can be, really: we live in our own places, and put our thoughts out there for everyone to share. But, living in our separate places - and perhaps more so here in the middle of the country - we Episcopal bloggers don't often gather. It was a nice addition to a good day to be able to share it with colleagues who, like me, want to reflect on, among other things, the joys (and occasional frustrations) of life in the Episcopal Church.

A Thought This Morning

2011-03-01T10:26:00.000-06:00

Lord, I have long ago lost my surprise that the unrighteous prosper. But, Lord, the obnoxious?

Medicare Preventive Services - Are We Using Our Money Well?

2011-02-24T12:05:00.000-06:00

I have written before about the importance of evaluating medical procedures to evaluate effectiveness. I’ve noted that this will be important under our new health care law, so that the Government and insurance companies pay for what works – and don’t pay for what doesn’t. But, as I’ve also noted, who of us really wants to receive a treatment that hasn’t been shown to work, much less one that has been shown not to work?

That has been the point of the US Preventive Services Task Force (USPSTF). The USPSTF is not in fact part of the new health care law. Instead, it is a program of the Agency for Healthcare Research and Quality (AHRQ) of the Department of Health and Human Services (HHS). It’s a panel of primary care physicians and epidemiologists who review published research to assess what works and what doesn’t. The program has functioned for more than twenty five years, but last year rose to public attention when it suggested new recommendations for mammograms.

With all that in mind, I wanted to take note of a recent article. A group of physicians has published, “Comparison Between US Preventive Services Task Force Recommendations and Medicare Coverage,” (Lesser et al, Annals of Family Medicine, Vol.9, No.1 [January-February], 2011). The Center for Medicare Services (CMS) has published recommendations for preventive services for Medicare patients (in 2007 and revised in 2009). The researchers compared those with recommendations from USPSTF, and looked at what Medicare would pay for. They looked both at individual preventive services, and also at what they identified as “preventive coordination:” that is, for coordination in addition to the service there needed to be reimbursement for risk assessment, patient motivation, and/or arranging the service. Much of this would be covered by the Welcome to Medicare Visit, an initial preventive physical exam for new Medicare beneficiaries. On the other hand, many were only covered as a part of the Welcome to Medicare Visit, and not if needed later. As a result, they stratified their results in four categories. “Fully covered” meant that both the service and preventive coordination as recommended by USPSTF were covered by Medicare. “Partially covered” meant that the service was covered, and preventive coordination was covered, but only as part of the Welcome to Medicare Visit. “Partial coverage with inconsistent indication” meant that the Medicare did reimburse for some patients and not for others. “No coverage” meant that the preventive services recommended by USPSTF were not covered by Medicare.

The researchers identified 15 preventive interventions recommended by USPSTF. While Medicare provided partial payment for 93% of the procedures (14 of 15), they provided full payment of both the procedure and for preventive coordination for only one (7%). On the other hand, the researchers identified 16 procedures that USPSTF recommends against, either fully or after a certain age. Medicare reimbursed for seven (44%), regardless of age. The researchers also noted that both USPSTF and Medicare recommended preventive services for at-risk populations, but sometimes defined those populations differently (focusing in different risks).

This is an interesting study. Medicare is the largest institution reimbursing providers for health care. CMS is continually searching (under no small pressure from the Executive and Legislative branches) for ways to support and provide appropriate care, and get the best bang for the buck. Effectiveness has gotten attention in the recent passage of our new health care law, but it has actually been an issue for some time. One would think it important that two agencies, both within the HHS, to talk with each other about recommendations. And perhaps they do; but these differences between what USPSTF recommends, based on review of the literature, and what Medicare recommends functionally (by being willing to pay for it) raise a question about that.

These days we’re inundated with news about how little money Government has (at all levels), and the necessity of controlling costs. (Remarkably, there are no discussions about raising revenue; but that’s a topic for another day.) Comparative effectiveness of medical interventions and efforts at preventive care are both important for controlling health care costs for the long term. Perhaps coordination will get better with time. Unfortunately, this study suggests that we aren’t coordinating well enough with the tools we already have.

One Further Reflection on the Lessons for Epiphany 7 - And on a "Christian Nation"

2011-02-21T10:35:00.000-06:00

Yesterday in the lesson from Leviticus we heard these verses:

^{⁹When you reap the harvest of your land, you shall not reap to the very edges of your field, or gather the gleanings of your harvest. ¹⁰You shall not strip your vineyard bare, or gather the fallen grapes of your vineyard; you shall leave them for the poor and the alien: I am the Lord your God. (Leviticus 19:9-10)}They were in context with this summary verse:

^{¹⁸You shall not take vengeance or bear a grudge against any of your people, but you shall love your neighbor as yourself: I am the Lord. (Leviticus 19:18)}Now, for the Israelite, there was no distinction of "church and state." These were laid down, effectively, as both religious and civil laws.

So, isn't this a Biblical mandate for social welfare? At least, isn't that where we would expect a Biblical conservative to some down, connecting this with, say, Matthew 25? Just wondering....

All You Need is Love: a Sermon for Epiphany 7, Year A

2011-02-19T21:46:00.000-06:00

As I read through the lessons for today, and especially the Old Testament and the Gospel lessons, I found myself thinking of a song. That will not surprise most of you. I found myself focusing on what it means to love your neighbor, and thinking of a song. But, it wasn’t enough to think of the song. I had to place the song in context.

Now, you know the song. It was “All You Need Is Love,” by the Beatles. We all know it:

All you need is love.
All you need is love.
All you need is love, love.
Love is all you need.

But, I didn’t just think of the song. I thought of it in a specific context: specifically, I thought of it in the movie, “Yellow Submarine.” If you haven’t seen it, “Yellow Submarine” might have been something of a soundtrack in search of a plot, but it was in its day quite a production. It was animated; and if it didn’t have the modern effects of 3D, it had the bright, exaggerated images of Peter Max. It was psychodelica in all its glory.

You can find it on YouTube, by the way. It’s broken up into seventeen parts, but it’s all there. Still, there was nothing like going to see it in a theater, up there on the big screen. Those colors and images could be just overwhelming! It was especially great at a midnight show. You sat there in the theater, with your date beside you; and almost as much fun as the movie itself were all the folks sitting in the front three rows in – let’s say in an altered state. They sat there, their heads thrown back and their eyes wide open, saying, “OH, GOD! OH, WOW! OH, GOD!”

I suppose we might not all remember that. Some would be too young, of course; and a few might be too old. And then there are those who don’t’ remember because they were sitting down there in the first three rows….

If you don’t know the movie, the story is that Pepperland, a paradise under the sea, is attacked by the Blue Meanies, with their fierce armies, their Apple Bonkers, their Snapping Turks, and especially their fiercest weapon, the terrible Flying Glove. Only Fred escapes, and makes his way to London where he finds the Beatles – who look astonishingly like Sergeant Pepper’s Lonely Hearts Club Band! Fred enlists them to go back with him, and together they are able to free Pepperland and drive out the Blue Meanies.

That’s where the song comes in. When the terrible Flying Glove attacks them, they sing, “All You Need is Love.” And as they sing, the words take form. They take on shape and substance; and it is the words. “All you need is love,” that defeat the Flying Glove and put the Meanies to flight.

And that’s what came to me as I reflected on the lessons. The words took on shape and substance, and love overcame evil.

That’s just like the lessons today. Think about the lesson from Leviticus. It begins with God’s blanket proclamation, “You shall be holy, because I the Lord your God am holy.” But, then, listen to what holiness looks like: you don’t harvest your field fencerow to fencerow. You don’t gather up every grape that falls to the ground. Instead, you leave it for the poor and the stranger. Holiness is about caring for others, even if it’s messy and inefficient, even if it costs you something.

You don’t steal, you don’t lie, you don’t make victims of the innocent. You aren’t unfair, you don’t slander, and you don’t take revenge. You love your neighbor as yourself, even when – especially when - you have an advantage. That’s what it means to be holy: love takes shape and form until what you do for another looks like what you would do for yourself.

That’s what Jesus was referring back to – but it sounds like things had deteriorated over time. “You have heard,” he said, “an eye for and eye, and a tooth for a tooth.” That is, you make the punishment fit the crime: you don’t overlook it, but neither do you overreact. But Jesus says that isn’t enough. And he doesn’t focus on what it means when you do the punishing, but when you’re the one getting punished. “Don’t resist the evil one,” he said, “Turn the other cheek. And, find ways to give more than is demanded. So, if you get sued for your coat, give it up - and not just your coat, but your tunic. And if you’re forced into labor, do twice as much as required. Find ways to give, even when it’s not deserved, even when it’s not fair.”

“And about that old attitude – ‘love your neighbor and hate your enemy’ – I’m telling you to love your enemy. After all, God makes the sun shine and the rain fall so that crops grow– and he does it whether the owner is just or unjust, righteous or unrighteous. Anyone can love a person who loves him back, or welcome a person who’ll welcome in return. You’re called to do more. You’re called to a love that can take some pain. You’ve got to give your love shape and substance, because that’s what it means to be perfect as the Lord your God is perfect.”

That’s what it was, you know, that brought to mind that scene from “Yellow Submarine.” As I said, again and again the words, “All you need is love,” took form and substance, and defeated the Flying Glove. But, they didn’t do it by breaking the Glove, or attacking it, or driving it off. Instead, the words were broken by the Glove, and yet they kept forming. They were smashed again and again, and yet they kept coming. The words didn’t resist, but simply faced the attack until the Glove was overwhelmed, not by force, but in the rubble of its own making.

We’re called to do more. We’re called to a love that serves others, even when it’s messy and inefficient and costly. We’re called to a love that will bear pain, and seek to give even in the face of injustice. We’re called to love our neighbor, and not just the neighbor who will love us back. We’re called to love our neighbor – even to suffer for our neighbor – just as we might love, and suffer for, ourselves.

Now, this is a hard teaching, and it raises an important question. Is Jesus asking us here to be so self-sacrificing as to be destructive to another or to ourselves? After all, life isn’t simple, and sometimes what seems kind at first can have harmful consequences. No matter how much the addict might plead, it isn’t really a kindness to provide the drug. We know as parents that, no matter how the child cries, what the child wants isn’t necessarily what the child needs.

Nor do I think Jesus is calling for us to be self-destructive. None of Jesus’ examples, nor those from Leviticus, were life threatening, or even all that unusual. Even the forced labor was permitted under Roman law. On the other hand, I think we need to think about this with real humility. After all, he also said there is no greater love than to lay down one’s life for another – and then proceeded to do so for us.

But, perhaps those questions are distractions. If we aren’t called to be self-destructive, neither does that let us off the hook. We are called to love neighbor as self, and not just the neighbor who loves us but the neighbor who hates us. We are called to love in ways that are messy, that cost us, that can cause us pain. We are called to be holy as God is holy, to be perfect as God is perfect. And if our love has shape and form and substance, love will truly be all we need.

Notes for Episcopal Chaplains (and Others)

2011-02-10T12:17:00.000-06:00

I have a couple of things I want to bring to your attention. First, a new edition of the AHN Newsletter is up on the Anglican Health Network web site. It's always a good reminder of healthcare activities across the Communion, many of which are supported in our institutions and our dioceses in the Episcopal Church. This edition has something closer to home: an article by AEHC member Matt Cobb about chaplaincy, AEHC, and international connections. The article begins on page 6. Go take a look.

And while you're looking, there's other articles of interest. On page 5 there's an article on chaplaincy in the National Health Service in the UK. It's an opportunity to consider a different model. The next article is from a psychologist at Rush University. Episcopal chaplaincy is well represented at Rush/Pres/St. Luke's from Bishop Anderson House. Spend some time with these and other articles in the AHN Newsletter.

The second thing I want to let you know about is plans for our AEHC events when the Association of Professional Chaplains (APC) meets next month in Dallas (you can get more details about the APC events here). All of our events will take place Friday, March 25, at the convention hotel, the Hyatt Regency DFW. Our speaker at the Banquet will be Lee Hogan, Program Director for the Anglican Health Network. Here is the schedule of events:

7:15- Holy Eucharist
8:15-Breakfast
9:15-Annual meeting
6:00p- Pre-Banquet reception in the Hospitality Suite Rm. # 1372
7:00- Banquet- Lee Hogan Program Director for the Anglican Health Network.

The cost of these events will be $100 total. Please send your registration and money to the address below:

Babs France
4223 Swift Ave
San Diego, CA 92104-6605

Folks on the AEHC e-list have received notice and a registration form, and there will also be a mailing to AEHC members; but there's no need for you to wait. Send your contact information and a check by March 11, and we'll be happy to have you join us.
So, check out the AHN Newsletter. Then, make plans to hear a representative of AHN when we gather for our annual meeting. I hope to see all of you there.

On Stories and Medicine and Faith

2011-02-09T09:36:00.001-06:00

It's been a big week for my work in other settings. Today my newest piece is up at Episcopal Cafe. It centers on the importance of stories: how they can be important for learning about health, and important for learning about the Christian faith. As always, I'd be happy to hear your comments on the post, whether at the Cafe or here.

In health care, stories are part of the field of "Narrative Medicine." If you're not familiar with it, let me suggest a place to start. Susan Palwick is a valued blog colleague. You can see a link to her blog, Rickety Contrivances of Doing Good, in my list because she's an Episcopal chaplain, volunteering in a local hospital emergency room and writing about it. She's also a published author (I can personally recommend The Necessary Beggar) and university professor; and in those capacities she lectures on Narrative Medicine at the medical school in Reno, Nevada. She has blogged about that, and you can look at some of that here. It's an interesting field, and should catch the notice of chaplains. I encourage you to take some time with what Susan has written.

Up Again at Ground Rounds.

2011-02-08T10:33:00.000-06:00

My post from last month on the Mississippi sisters has been accepted for this week's Grand Rounds. I always think it's an honor to be accepted, and to be included in good company. Take a look at what others have submitted. There are some great articles that could pique a chaplain's interest.

I have written before about Grand Rounds, the ongoing blog carnival on health care. As a "blog carnival," it collects blog posts from across the web and across health care, offering great stuff for clinical, ethical, and, yes, spiritual reflection. It's new every week, and on a different site. So, if you're interested in following it, check out the Grand Rounds Archive and Schedule. That way, you can look in frequently, and always be in the know.

Remembering the Dorchester Chaplains

2011-02-03T13:03:00.000-06:00

Perhaps it’s the cold weather by itself. Perhaps it’s because I haven’t been home in a while because of the weather (my decision and my wife’s, and not my hospital’s). For one reason or another, there is something particularly resonant about the observation today of the lesser feast of the Dorchester Chaplains.

The Dorchester Chaplains were military chaplains. Their story is told in the book, No Greater Glory by Dan Kurzman. They were chaplains in the United States Army shipping with troops on the USAT Dorchester when on February 3, 1943, it was attacked and sunk by a submarine of the Navy of Nazi Germany. In the midst literally of fire, flood, and terror, they cared for those in their charge. They offered support, they assisted into the lifeboats, and gave up their life jackets. They stayed with the ship, witnessed to be praying together by one of the last witnesses; and together they disappeared into dark, cold waters. “Greater love has no one than this: to lay down one’s life for one’s friends.”

And in that light, I am reflective on this morning’s temperatures – 10 degrees below 0F when I woke this morning – and conscious how I would fare exposed as they were. A verse from today’s Daily Office lesson – “For you shall go out in joy, and be led back in peace” (Isaiah 55:12) – sounds different, feels different for these who died in the midst of war.

I have written before of my esteem for my colleagues in military chaplaincy. They provide care in difficult circumstances, and protect freedom to practice religion for those whose time and place are not under their control. I can appreciate their work, when mine has much in common with theirs; but rarely in my career (for good or ill, I can’t say “never”) has my ministry required anything like their sacrifice and risk. This is a day to remember the peaceful, compassionate ministries and sacrifice of the Dorchester Chaplains; and to appreciate the peaceful, compassionate ministries and sacrifices of their colleagues who continue to serve.

On Mathematics as a Language of Faith

2011-01-29T20:27:00.001-06:00

You may recall a few months ago when I commented on the language of the New Atheists, and how very like the language of theology it is, both in form and function - how much it is in fact a "language of faith."

Well, I was fascinated by Brian Greene's appearance this past week on "The Colbert Report." Watch, and see just how much spirit (if not Spirit) there is in Greene's understanding of mathematics (a tone that is not lost on Colbert):

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Now, I'm not suggesting that Greene is one of the "New Atheists." I haven't heard him on that topic. Moreover, I'm not rejecting what he's saying. I think that he's doing his best to describe what he's discerning, and I think he's quite possibly accurate.

However, like many I think he overstates what mathematics is. It is in fact a language, one that is pretty good at describing concisely some known phenomena, and at speculating about implications of those phenomena. Theological language does the same thing. We watch how light changes from a star far away, and infer from those changes that a planet orbits that star. The math suggests that's how a planet would affect the light of a star. The thing is, unless and until we can actually send someone to confirm it (something I sincerely believe we will one day accomplish), it remains a faith statement.

I look at how the world operates, in all its consistency, and at how love seems to shape experience. I see in that evidence of God. I know it's a faith statement, but it's also based on observations, and the language of theology suggests that's how God will be perceived.

So, let's appreciate all that we can observe and learn that is best described in the language of mathematics. Let's also recognize that, like any other language, it has its limits; and that, for all our conviction, mathematical consistency is no more "proof" than theological consistency. Until we can experience things directly, both are essentially faith statements.

News of Note: We're In the Loop

2011-01-28T11:31:00.000-06:00

If you haven’t seen it, let me draw your attention to this report from the Episcopal News Service. It refers to a telephone conference call with Health and Human Services Secretary Kathleen Sebelius on implementing the Affordable Care Act. She included in the conference call a number of religious leaders, including the Rt. Rev. Barry Howe, Bishop of West Missouri. Yes, as you read down you’ll see that he is my bishop, and that he because he is Bishop of West Missouri he also serves on the Board of the Saint Luke’s Health System, and is Chair of the Board of our central referral hospital. So, naturally, this would be important to me.

However, I also want to note that it has meaning for Episcopalians beyond West Missouri. Bishop Howe is also a member and past Chair of the Standing Commission on Health of the General Convention. So, in a real sense he was representative of the Episcopal Church, both as a bishop but also as a member of that Commission.

This is not the first time that the Obama team has reached out to the faith communities specifically about health care. During the last presidential campaign I participated in a conference call on the topic coordinated with the Obama campaign staff by PICO National Network (which was also represented on this call). Perhaps there is a sense here that the faith communities can collaborate with government in pursuing social welfare, instead of simply substitutes (and poorly funded substitutes at that!) for government programs.

So, take a look at the news story. The Episcopal Church has long had a commitment to universal access to health care. Now those in government who share that commitment want us informed and involved, too.

Good Theological Discussion Can Be Had - and Here's One Example.

2011-01-23T10:01:00.000-06:00

There are those who suggest that lively theological discussion doesn't happen in the Episcopal Church; or that the conclusions are so determined by current social fashion as to make the discussion short, predictable, and vapid.

With that in mind, I'd like to invite my regular readers to an active online discussion led by one of my colleagues at the Episcopal Cafe. Derek Olson has written in three parts a discourse on "Communion Without Baptism." We all know that it happens occasionally, just because few of us want to set "crossing guards" between the front pews and the communion rails. The question is whether we should make that an acceptable option (as happens in the invitation in a few congregations), or an exception to the norm to be addressed pastorally and individually.

It's a great discussion, and you can get in on it. Read the first part, the second part, and the third part; and with each part read the comments. Feel free, too, to add your own comments. Sure, it will take a while - but, then, good theological reflection in community does take a while. And this is good theological reflection, and well worth your time. So, sit down, grab your favorite beverage, and get into it.

Spending the Time: Reflections for Epiphany 2, Year A

2011-01-16T20:06:00.000-06:00

This sermon, or something like it, preached 1/16/11 at St. Mary Magdalene Episcopal Church, Kansas City.

Those who know anything about me at all know that I love music – in eclectic, almost chaotic variety. Most also know that I call myself “a noise person.” I prefer not to work in silence, but to have something in the background.

So, it shouldn’t be any surprise that I have music playing in the background while I work. Usually, it’s from the web site Pandora, where I have several “channels.” Usually, I’m not paying all that much attention. But one day, not long ago, I heard this:

In a seedy karaoke bar by the banks of the mighty Bosphorus
There’s a Japanese man in a business suit singing “Smoke Gets In Your Eyes.”

What?

And the muscular cyborg German men dance with sexy French Canadians,
And the overweight Americans wear their patriotic jumpsuits.

Wow! Now, if you’re at all a fan of the poets Bob Dylan or e. e. cummings, or even Walt Whitman, you have some sense of lyrics that can be put together just because the words feel right. Still, I was intrigued. I also realized that what I had heard was the last verse, the end. I wanted to hear more. So, I started to listen for the song.

Soon enough it came up again, and I listened with more care. That’s how I caught the first verse.

In a wooden boat in the shipping lanes with the freighters towering over me,
I can hear the jets flying overhead, leaving trails across the darkening sky.
And as the sun is going down I can take a taxi into town,
And the waiter at the restaurant sets a table just for one.

Cool! This was just as interesting an image as the last verse. Of course, there was no obvious connection, except perhaps the reference to the Bosphorus, one of the busiest shipping channels in the world. But, the song had me, and I wanted to know more.

Fortunately, from Pandora I had the name of the song and the name of the group: “Wheels” by the group Cake. With that, then, I was able to go to that other online reference for contemporary culture, YouTube. There I found the middle, the second verse that brought it together.

So I had a plane to take me to a place so far away from you,
Eventually we began to see that we could be completely free.
And I could get away from you, and you could get away from me,
And we could live each separately in our cities in the sun.

Now, with that the song made some sense. It’s a song about the failure of a relationship, and looking for a “geographical solution:” running away. Having run away, the first and last verses show us just how far the singer had run, both geographically and emotionally; and just how empty he had found the new life he had run to.

I came to like the song a lot, and to appreciate the poetry of it. But if I hadn’t gone beyond my initial interest and taken the time to hear it out, I would never have put it all together.

There’s something like this going on in today’s Gospel lesson. This is a short passage, but it speaks of events over several days. It begins with John’s proclamation of who Jesus is, and how Jesus is the fulfillment of all that John has been preaching. “Here is the Lamb of God, here is the Son of God. Here is one I’ve been talking about!” And he’s not just saying this once. The lesson says he said it from one day to the next.

Two of John’s disciples hear it, proclaimed aloud as Jesus passes: “Here is the Lamb of God.” They take off after Jesus. Clearly they’re intrigued. Jesus notices, turns and says, “What are you looking for?”

They don’t really answer. Perhaps they don’t know how to answer. So, they say, “Rabbi, where are you staying?” Jesus does answer, but his answer is not a location but an invitation: “Come and see.”

They are intrigued, and so they follow. But, more important, they stay. “They came and saw where he was staying, and they remained with him that day. It was about four o’clock in the afternoon.” That verse has intrigued me, because there are several possibilities of meaning here. One is that from that point, from that day, they remained followers of Jesus, and never returned to John. Another is a simple note of time: they stayed all day, or all that was left of it.

I found myself thinking about that reference to time: “It was about 4:00 o’clock;” or, in a more literal translation, “It was about the tenth hour.” Did they join Jesus late in the day? Or, did they follow Jesus earlier and stay with him into the late afternoon? The sentence is really just dropped in there – a time reference with little context – without clear connection to the verse before.

Or, for that matter, to what comes after. Here is the next event: “ He [that is, Andrew] first found his brother Simon and said to him, “We have found the Messiah” (which is translated Anointed).” First thing after Jesus invited them? First thing when they decided to stay with Jesus? First thing the next morning? It’s not really clear.

What seems interesting to me in this is that time seems to be passing in all of this, however concisely it’s reported. Andrew and another heard John, and followed Jesus, and then spent some time. It was sometime late in the day or early the next morning – sometime after they’d first followed Jesus – that Andrew can say to Peter, “We have found the Messiah.”

And perhaps even more time passes. Those scholars who want to harmonize John’s report with the report in Mark and Matthew suggest that Peter and Andrew, and also James and John, were prepared to leave their boats and follow because they had first met him well before, as reported by John.

What strikes me about all of this is that all our important relationships are like that. They begin with a sense of excitement and curiosity, but it’s only with time that they become mature, and we discover who the other person is. It’s certainly true of being in love. There’s that first flush of infatuation, but it takes time to know and love the person as he or she is. It’s true for us as parents. We’re enchanted with that new child, but really loving the child comes as the child grows and changes and becomes a person.

It’s also true of our relationship with Christ, and with his Body, the Church. Like the first disciples we find something compelling about Jesus. We hear for ourselves that invitation, “Come and see.” And yet it takes time for us to grow in that relationship, to discover for ourselves what it means, and what it means for us, that Jesus is the Messiah. It takes time for us to discover our various vocations, and to find our place in the Church.

Perhaps that especially true for us in the Episcopal Church. After all, when someone asks, “What it the Episcopal Church about,” our answer is, “Come and spend some time. To see who we are, how we understand the Christian faith, come and worship with us for a while.” Sure, we do put it into a book – but it’s a book to structure a life of prayer and worship, and not a set of theological propositions.

And if that’s true of our experience of the faith, that it’s not just about coming to Christ but also about growing in Christ, what does it say about how we bring others to Christ? It is not enough for us to point to Christ, to say, “There is the Messiah.” We are also called to show them Christ, to help them learn what we have learned, what Andrew learned so that he called Peter. We need to be ourselves the light to the nations, reflecting God’s light so that those we encounter will not only come and see, but also want to come and stay. That is about welcome, certainly; but it’s also about a profound hospitality of the kind that held Andrew on that day and in the days that followed, that led Andrew to invite others, beginning with his own brother.

Like Andrew, we find Christ compelling. And like Andrew, we need to spend some time with Christ so that we can learn what it really means to say, “We think we have found the Messiah.” We are called to invite others, and to provide them the hospitality that encourages them to learn what we mean when we say, “We have found the Messiah.” It isn’t enough for us to respond with someone says, “Behold the Lamb of God,” or for us to say that to another. We need to commit ourselves, and to invite others to “Come and see; come and stay; come and grow!”

I'm Up Again...

2011-01-06T09:43:00.000-06:00

at the Episcopal Cafe. My first piece for the new year went up today. And don't let the headline frighten you: I haven't lost my Biblical center or my orthodoxy. I'm really concerned about the limits of the phrase "an organic communion," and the way I think we often conflate that with our image of the Body of Christ.

Well, you may or may not agree. So, take a look; and feel free to let me know what you think, whether at the Cafe or here. We can have some good discussions (look at the one about the General Ordination Exams), and we'd be happy to have you come join the fun.

The Georgetown Mantra and the Mississippi Sisters

2011-01-03T09:52:00.002-06:00

Well, it’s been all over the news: Governor Haley Barbour has examined the cases of Jamie and Gladys Scott, two sisters in the Mississippi Correctional System. They were convicted of participating in a robbery, and each received life sentences. To this point, they have served sixteen years.

Now, these women have been subjects of discussion for some time as possible recipients of clemency. First, the robbery netted $11.00. The young men who were also participants, who actually struck the victims and took their wallets, all received much shorter sentences. In general, a life sentence for participation in the crime in question is quite exceptionally long.

Governor Barbour has decided they can leave prison. Unusually, he has not decided to commute their sentences. Instead, he has decided to suspend their sentences. An important difference between commutting the sentences and suspending the sentences is that once committed, the sentence is ended, while a suspension can be made conditional.

And in this case, there is reportedly a condition, at least for one of the sisters. Jamie is in kidney failure and quite ill. Her care requires dialysis. Her suspension is on compassionate grounds, although the governor was explicit that the cost to the state of Jamie’s dialysis was also an issue. For Gladys, on the other hand, there is a condition for the suspension of her sentence: that she donate a kidney to be transplanted into her sister. Now, this is something that Gladys is willing to do; indeed, it was her idea. However, that raises a question of why it should be made a condition. Fact is, it’s not known whether she’s actually a compatible donor. The sisters share a blood type, and that’s some indication, but it’s not the only measure.

In news reports and in blog comments, it’s been widely noted that this raises all sorts of ethical questions. However, I haven’t yet found an analysis of why. So, I thought I’d consider the question in light of the Georgetown Mantra.

The first category to consider in the Mantra is that of Autonomy. There are a number of questions related to autonomy, and these are initially the thorniest when considering donation. First, there are actually two patients here, Jamie and Gladys. The issues of autonomy for Jamie, at least initially, seem straightforward. Does she wish to receive a transplant? Conceivably, she could prefer to continue dialysis, although that certainly has its own risks for her. However, at this point it appears she is prepared to receive a transplanted kidney from her sister.

That said, I would raise a question of whether she understands the consequences of the transplant. If things go well, she will have a functioning kidney. However, to protect the new kidney from rejection and infection, she will also be committed to a regimen of drugs for the rest of her life. This is the case for all transplant recipients, and they accept it gratefully. However, if Jamie has not thought about this, we can question whether her consent is properly informed.

For Gladys, on the other hand, the issues of autonomy are more complicated. She has expressed her willingness to donate a kidney to her sister. However, in the situation as presented, we have to raise the question of whether this is a free choice. When we think about consent to a procedure, we usually worry about whether the patient’s consent is informed. However, there is also a concern about whether the patient’s consent is free – free from inappropriate inducement or coercion. In research, prisoners are considered a protected class, a group whose consent is questionable because the freedom to consent isn’t necessarily free. In Gladys’ case, the primary question raised has been whether suspension of a life sentence is excessive inducement. More to the point, is rejection of the suspension of her sentence so significant a threat as to be coercive? This would be an important question in any procedure, whether for research or for therapy. However, this is in relation to a transplant procedure, one that, while not requiring that Gladys die, does entail significant risks. First and foremost, it leaves Gladys with one functioning kidney herself. Suppose that now she should develop kidney failure. Her sister did, and it’s conceivable that she might. By and large, a person can function with one kidney, and we are blessed with the redundant system of having two. Thus, if one fails, the other can function; or if both are disabled, between the two they might continue to maintain function equivalent to two. For Jamie, this is not the issue. Her kidneys together do not function well enough to sustain her. With the new kidney she would have one functioning, which is more than she has now. However, for Gladys she is reducing from two to one, with the consequent risks. Those risks are known, calculable, and relatively small. However, the question remains whether making the donation a condition for the suspension of a life sentence in prison is coercive.

The second category to consider for these two sisters is Non-maleficence, summarized in the well-known premise, “First, do no harm.” Once again, for Jamie this seems straightforward. There are risks for her in the procedure, but in general we’re not concerned for her in avoiding harm.

For Gladys, on the other hand, there is potential for harm. She is, after all, taking a significant risk, and increasing her risks for the future. In addition to the risks we’ve already referenced regarding the loss of a kidney, there are also the risks related directly to the surgical procedure. Once again, these are known, calculable, and manageable, but they are significant.

The third category is Beneficence, determination of the patient’s best interest. Again, for Jamie this seems simple. It is not in her best interest for her kidney failure to go untreated; and with the risks and significant limitations related to dialysis, a kidney transplant seems in her interest.

There remains, though, the question of Gladys’ best interest. She is making a sacrifice at measurable physical risk. However, there is also the interest of having her sister survive. While we tend to focus on the physical risks, the emotional benefits of her generosity, and of the continuing relationship with her sister, are interests we need to appreciate.

Finally, there is the question of Justice, which I commonly describe as how these issues affect society. In this instance we have issues of justice in the narrower, legal sense. Both women are prisoners serving life sentences, convicted presumably by juries of their peers. There is arguably some effect to society in suspending these sentences. This is countered to some extent by the argument that a life sentence for the crimes in question was in itself unjust.

The governor also acknowledged the concern about the cost of providing care for Jamie in the correctional system. Dialysis is certainly costly, and is an expense ongoing until Jamie’s death. The medications to maintain a transplanted kidney are also costly; but if the sentence is suspended, presumably the costs won’t be born by the state of Mississippi. That may be temporary as well, in that she may need support from Medicaid; but I can only imagine that this has been calculated as well.

While we resist discussing dollars in health care, they are important. Funds are limited, and so money spent on Jamie is not available for the care of other prisoners, or for other activities of the state. It is a reasonable question as to whether continuing to spend the costs of dialysis serves the interests of the people of Mississippi. In fact it is a reasonable question whether continuing the costs of imprisoning these two elderly women serves the interest of the people of Mississippi.

At the same time, there are also issues of justice that are common in all cases of transplantation. It is well known just how small supply of organs donated is in relation to the possible recipients. A real-life exercise in “lifeboat ethics” is the function of a Transplant Committee is to decide which of a number of eligible patients will receive a donated organ. Family donations are a special case, both because of the greater likelihood that the siblings will be a match, and also because rarely are there any other circumstances in which a donation can be directed. Now, while Gladys might well be altruistic enough to be a registered organ donor for a stranger, we can ask whether she would willing to be a living kidney donor for a stranger, or whether any other donation would wait for her death. This affects the supply of a scarce resource, and so to some extent, however small, all the possibly eligible recipients on the list.

The possibility that the condition of the suspension might be coercive also raises a justice issue. If Gladys can be coerced into donating a kidney (even if she’s actually willing), to what possible ends can other prisoners be coerced, or at least inappropriately persuaded? This is an especially difficult issue in organ donation in light of allegations that in China organs for donation are recovered from executed prisoners, with no consideration of consent; or that in South Asia poor donors are persuaded with large amounts of money to donate kidneys that are then available to foreign recipients based, not solely on good clinical criteria, but also on the ability to pay. While there are limits to a “slippery slope” argument, this is certainly one place we might expect one.

There could be more complete reflection on this case. However, this seems to me an appropriate beginning to consider the case in light of a set of well-known principles in medical ethics. I imagine others will go to greater length, largely in academic publications. I thought it worthwhile to get the conversation started here. So, here are my thoughts. The thoughts of others are welcome.

Resources on DNR, AND, and Advance Directives.

2010-12-17T19:39:00.001-06:00

I received this comment on my previous post:

Rev. Scott: You're right to encourage people to complete an advance directive, and also right to note that few do. One reason is that, as you note, people are often unfamiliar with the medical and legal terms. Many people have found our Five Wishes advance directive is a way of both starting the conversation, designating a health care agent, and giving that person instruction on what is wanted or not wanted. There are over 15 million in national circulation, distributed by some 23,000 partner organizations including churches. Learn more at www.agingwithdignity.org. --Paul Malley, President, Aging with Dignity

Mr. Malley has pointed to one good resource, and I thought it worthwhile to link it, and a couple of others.

Five Wishes from Aging with Dignity. Mr Malley has pointed to perhaps the best known single program nationwide for not only making decisions about health care, but actually thinking them through.
The Caring Conversations program of the Center for Practical Bioethics. While I'm especially proud of the Kansas City-based Center for Practical Bioethics, the Center is nationally recognized in promoting advance directive planning. The Caring Conversations program makes available in print or for download a workbook and forms in English and Spanish, as well as specialized workbooks for young adults and for aging military veterans.
The Advance Directive page from Caring Conversations, a program of the National Hospice and Palliative Care Organization (NHPCO). NHPCO is one of the best known organizations supporting hospice and palliative care in the United States. A feature of their page is a list of links allowing the user to download forms acceptable in each of the fifty states and the District of Columbia.

While there are many good resources available - indeed, you can request forms from any health care institution that accepts Medicare, and probably from most that don't - these are from organizations that are widely known and respected. Feel free to review these resources, learn from them, use them, and share them. I appreciate Mr. Malley's comment, and absolutely agree: all of us, really, need to be informed about these issues, and to make and share our decisions before they become critical.

Further Consideration of DNR and AND Orders: Thoughts on Public (Lack of) Awareness

2010-12-15T14:33:00.001-06:00

I have written before about Do Not Resuscitate (DNR) orders and a recent effort to reframe them as Allow Natural Death (AND) orders. Last week there was a post on the subject on a New York Times blog.

There wasn’t really anything new in the article itself. It does, however, cite a research article more recent than the two I cited in a post last year (here and here). In fact, this study was a replication of one that I cited. I think replicating studies is a good thing, and this one basically confirmed the earlier results. (The study had the limitation of being a convenience sample; but I did find it interesting that it included a detailed list of the religious preferences of participants, and that two Episcopalians participated.)

Being the wonk I can sometimes be, I also took the time to read all the comments on the article. Those comments were also interesting. While something of a convenience sample in its own right, the comments also confirmed my own experience in some ways I thought worth note.

When I reviewed the comments, there were 65. While there were some professionals (physicians, nurses, EMT’s, etc), most respondents were, at least from what was shared, were not healthcare professionals. Some, both professional and non-professional, related specific events that shaped their thoughts, but most did not. All addressed in one way or another, the medical terminology of DNR and AND, and whether or not one term was preferable. A few respondents even suggested other terms they thought might be more acceptable. Mine is not a scientific, or even a statistical analysis. However, I think some themes were visible that I think reflect the current state of affairs.

* First, folks in the lay community are confused about not only the terms DNR or AND, but the variety of ways that care at the end of life can be shaped. Folks out there have heard the various terms of DNR (and now AND), Living Will, Advance Directive, Health Care Treatment Directive, and Durable Power of Attorney (DPOA) for Health Care; but they don’t know the differences among them. This became clear from the number of folks who wrote about a patient “signing a DNR,” which does not apply to DNR or AND orders, but to Living Will and Health Care Directive documents. I can’t say I’m surprised that lay folk are confused about these distinctions. I educate nurses regularly about the differences.

One particular distinction that lay folk weren’t familiar with was that a DNR order (or an AND order) is in fact a very limited order. It applies when and if – and only when and if – there is a specific event that might call for CPR. It doesn’t affect the identified plan for care, whether the plan is to cure or to provide palliative or comfort care, unless such an event takes place. On the other hand, Living Wills and Health Care Directives offer directions that can shape care, and that apply in broader circumstances.

* A second theme is that the movement to develop Physician Orders for Life Sustaining Treatment (POLST) is spreading, and has legal standing in some states. Professionals among the respondents referred to various acronyms, but all were based on the POLST model. Like a Health Care Directive, a POLST-type document is completed by the patient before there is need. Like a DNR or AND order, a POLST-type document is completed with the assistance of a doctor or other advanced practice professional, and is a set of orders. There is some reason to think that they will be the step beyond Health Care Directives, in that the patient's preferences have the force of medical orders. On the other hand, they can be misunderstood. It was efforts to get Medicare funding for the time physicians and others spend with patients to complete POLST-type documents that triggered all the misleading "death panel" talk during the buildup to the new health care law.

* Few respondents expressed concern about their own deaths, but a number expressed concern about the death of another. That is, some were concerned that care might be withdrawn inappropriately and prematurely, primarily because of Living Wills and Health Care Treatment Directives. I have long said that few people are afraid of being dead, but many are afraid of the dying process. This is something different, although not a surprise: fewer folks are anxious about their own deaths or decisions, and more are concerned about decisions made for others and/or by others.

This is also consistent with my experience. Family members struggle when asked to make decisions that change the goals of care from cure to comfort. The various forms of Advanced Directives are supposed to help with that, and they do. It is easier on a family member to hear and support, "This is the preference your loved one has expressed," than, "What do you think?" However, there are still folks who fear that doctors will slant their information and decisions based on personal bias and/or business concerns, including some who responded to the story.

I think these are important issues that need to be addressed through education. That includes education of lay folk, but also of professionals. While the professionals responding to this blog post knew their business, I encounter professionals who don’t, and so can’t properly inform or educate patients and families. Sometimes, too, the poor information causes them unnecessary ethical questions in the course of providing care (not to say that there aren’t necessary ethical questions; but some are also unnecessary).

As a chaplain, and especially as a chaplain long involved in clinical ethics in hospitals where I have worked, these points of confusion or lack of information make it harder than necessary to make decisions consonant with the wishes of patients and/or families, and harder than necessary to communicate the decisions we make. Even as we support patients’ rights to make in advance decisions about their health care – including decisions that are different from those we might make, or even approve of – we need to have our terms straight and our information clear. It won’t eliminate our fear of the dying process; but it may well make it easier for patients to tell us about the care they want, and for those of us providing and supporting care to work together to meet those wishes.

An Episcopal Perspective: Distinctions That Episcopal Chaplains Bring to Health Care Ministries

2010-12-14T17:32:00.000-06:00

I wrote this article for Chaplair, the newsletter of the Assembly of Episcopal Healthcare Chaplains (AEHC). The latest issue of Chaplair is now in print, and so I feel free to also share the article here.

When I first began writing a blog four years ago, I had one topic that I especially wanted to think about. That is whether there might be an Episcopal culture for health care, comparable to the distinctive cultures of, say, Roman Catholics or Seventh-day Adventists.

As I wrote about it (for me, a way of thinking out loud), I identified some characteristics that I thought an Episcopal culture might include. For example, the General Convention has never given specific directives on health care procedures. We have made some clear statements, but not statements that somehow separated us within the larger health care community.

I haven’t given up on the concept of an Episcopal culture for health care, even though I don’t think I’ve found it yet. However, I do think some of the characteristics I have discerned do give the Episcopal Church something important to offer in chaplaincy, and for us to offer as Episcopal chaplains.

We are remarkably well prepared to work in the multicultural, multifaith, polyglot environment of contemporary health care. Central to this is our commitment to the Baptismal Covenant. We have embraced as definitive of the Christian life, and certainly of our Christian ministry, that we will serve Christ by serving all persons, and loving neighbor as self. We have claimed for ourselves that we will “strive for justice and peace among all people, “ and not just our own; and that we will “respect the dignity of every human being,” and not just those who agree with us. Certainly, all professional chaplains commit to these things in codes of ethics and professional standards. We, however, have declared this as fundamental to our faith and practice as Episcopalians.

We are also, I think, well prepared to speak of the eternal in a variety of images. This is in part because we embrace all of Scripture as meaningful, while recognizing that in Scripture God is described in many ways, and addressed in many titles. We have made this formative for us in how many of these titles have been reflected in the Book of Common Prayer. Consider the variety of attributions of God in the many Collects of the church year, both in the Collects for Sundays and in those of feast days. Think of the many titles of God provided in the Psalms. I find this variety makes it very straightforward for me to pray in multifaith groups in ways that respect both my listeners and my own faith.

We have an appreciation of the power of liturgy, of structured and familiar responses, in the most significant moments of life. We certainly know the reality of that for folks like us from “liturgical churches.” However, I think many, if not most of us, have experienced how true this also is for those who claim other traditions. Once again, the Book of Common Prayer is a resource. Even when our words are not the appropriate words per se, we have experience structuring words and phrases to express the concerns and feelings of those in crisis. And, how many of us have discovered a chaplain colleague from another tradition making use of the Book of Common Prayer in her or his own professional practice?

As AEHC has gathered over the years I have advocated that we chaplains claim our place in the church. Many have heard me say, “As we are the Episcopalians among the health care chaplains, we are also the health care chaplains in the Episcopal Church.” It is also the case, however, that we are the Episcopalians among the health care chaplains. We have not defined our presence in our society to any extent by distinctive positions on medical practices. We do, however, bring tools and perspectives to health care chaplaincy that allow us to standout among our colleagues, and to serve patients, families, and staff from many traditions.

The Power of Words, Even in Our Own Voices

2010-12-04T17:07:00.001-06:00

I had an interesting experience yesterday. On a whim, I attended a monthly meeting of the Grief Support Network. This is a great local organization, with an excellent web site and resources. There is a monthly meeting with a speaker, and the topics are always interesting. However, I can’t usually go. I have a standing meeting at the hospital at a conflicting time, one that I can’t miss. Yesterday the meeting was cancelled, and I decided to take advantage of the opportunity.

The topic was “forgiveness,” and especially forgiving oneself. As a part of the presentation, the speaker passed out a “mirror script” – that is, a set of affirmations one might read to oneself. By reading the affirmations while looking in a mirror, one can get something of the experience of hearing them from another person, adding a sense of visible presence to hearing the words. Since we didn’t have mirrors in the meeting, the speaker had us pair off and read them to one another. Each of us heard this list of affirmations read by another.

As is always the case with such exercises, it felt stilted and awkward and artificial (even though each of us did his or her best to read the words with some feeling). Beyond that, I am of a certain age and a certain inclination. So, with all due respect to the presenter, I couldn’t get out of my head the image of Stuart Smalley, the character from Saturday Night Live.

But also I did feel something. Even in that artificial setting, the words were good to hear. And, since I am really pretty conscious of and concerned about my sins, I do have those things in my history for which I feel some need to forgive myself, even where I have been forgiven by another or when my concern is less a misdeed and more simple failure to meet my own standards. So, I was aware of my need for forgiveness, and hearing the affirmations did feel good.

That happens more often than we know. I frequently speak with students or others about reflective listening. Of course, critical to reflective listening is testing out and confirming what one has heard. So, often when reflective listening is taught the first step is, “What I hear you saying is….” That little piece of script also feels stilted and awkward and artificial. As a result, many students in the helping professions resist that phrase. Unfortunately, they end up also resisting the practice. As the student resists saying, “What I hear you saying is…,” the student also ends up not simply repeating back, but also interpreting and answering. The student doesn’t confirm, but instead tries to take the next step – and sometimes in fact they haven’t heard what the speaker intended, but don’t know because they haven’t confirmed.

So, the educator presses back again: “Make sure you’ve understood. Again: ‘What I hear you saying is….’” As artificial as it seems, the students work through the exercise; and they discover that, as artificial as it seems, the students feel better for having felt heard.

Some readers may be aware of the computer program ELIZA. ELIZA was originally intended as a means to test how humans might interact with computers, and whether a program could be written well enough that a user might not be able to tell whether he or she was relating to the program or to a human being.

A DOCTOR script was written for ELIZA, that did a pretty good job of simulating reflective listening. Remember, too, that this was back in the days of teletype interfaces and early CRT displays, so there was nothing like the capacity to simulate interaction that our more sophisticated programs manage today. However, even when simply reading the words as they clattered on the printer or as they appeared on an old green monitor, and even when the user was conscious that he or she was relating to a computer, folks felt better and felt heard. Some also attributed meaning and even feelings to the computer. This was consistent enough, and also disturbing enough to the researcher, that he dubbed it “the ELIZA Effect,” to describe humans projecting feelings onto computer interactions.

While I’m sure some projection of the users’ own feelings was going on, I also think that there was something about reading those words and processing them in the users’ minds that was meaningful for the users. That is, the users found it comforting and affirming to receive and think about those words, even in the artificial syntax of explicit reflective listening, and even in the artificial setting of an early computer interface. The words were powerful enough in themselves and in the minds of the users that it didn’t matter that the users knew they were interacting with a computer program with no intelligence of its own, much less emotion. The computer program didn’t in any sense really care, and yet the words were sufficiently powerful enough that users felt cared for – and some felt it strongly enough to project a sense of emotion onto the program.

My point is simply to reflect on the power of words for us human beings, and for the value of hearing words that clarify and comfort and affirm. They are powerful, even if the context seems awkward and artificial. They are meaningful, even if the words themselves seem stilted and trite. We enjoy them, and even benefit from them, however we hear them – even in our own voices, spoken to a mirror.

Toward a Sacramental Vote

2010-12-01T21:44:00.001-06:00

I don’t know about you, but I’ve been thoroughly disgusted by all the political stuff this fall. I voted, but as the day approached, the sheer volume of political noise around me (both as a measure of quantity and of intensity) was no fun. With each election in these United States I envy more civilized nations with distinct, and limited, campaigning seasons – and the shorter the better.

Interestingly, I had two elections to require my attention, both coincidentally in the same week. We had in my diocese the election of our next bishop. That election, with its relatively minute electorate, took hours longer than my civic participation.

We have complained early and often that siblings in other Anglican churches “don’t get” our processes for making decisions, whether electing bishops or changing our canons. We vote. That’s not to say that nothing is ever done by a small group in the background. However, sooner or later things come out into a very public light for resolution – well, most things, anyway.

I remember well when I first really thought about voting in the church. It wasn’t that I hadn’t always seen it, but since it was “what we do,” I hadn’t much thought about it. However, in 1976 I went to be a Visitor at the General Convention in Minneapolis. (Yes, at General Convention Visitor is a particular status, and if you haven’t any other reason to attend, I encourage you to go as a Visitor.) As a part of my preparation, I read a book on the General Convention (a title that, sadly, has been lost over the years). It described the process as we carry it out, and the structure within which we do it. Something that stood out to me, though, was the theological reflection on why we do things by vote.

The author’s point was new to me in 1976, but would now be familiar to many of us. Each of us participates in the life of the Spirit through baptism; and through baptism the Spirit participates in the life of each of us. Each of us has some awareness, some insight to contribute about how the Spirit is moving and calling in each of us. So, the more of us involved in the conversation, the better we believe we understand how the Spirit is moving and calling us as a body. This is not to ignore or deny Scripture and Tradition. Rather, it is to trust both that Scripture and Tradition reflect how the Spirit has moved and called us in the past, and also that it is in and through the Spirit that we understand what Scripture and Tradition are saying to us today. It is, though, to maintain that the Spirit of Christ is alive and active in our midst, if only we will listen. It is also to maintain that the Spirit calls each of us equally – equal at least in that the Spirit calls us each as much as the Spirit can; and that differences are matters of our preparation, our willingness, and our capacity to listen, and not of the Spirit valuing some of us more than others.

When we vote, to the extent we are intentional and prayerful we are making that action of the Spirit incarnate and sacramental. It is incarnate because we give it substance. It is sacramental because our intent is to make outward and visible what we feel is inward and spiritual. Sure, voting is not a perfect system for that, and consensus (when we can seek it, much less achieve it) might seem clearer evidence of the unity of the Spirit’s purpose; but we do it as the best we can in most instances, acknowledging those differences of preparation, willingness, and capacity. So, we don’t vote simply because it’s “the American way.” We vote with the intent of expressing each individual’s sense of the Spirit’s leading and of seeking to be guided by the greatest number of those individual expressions.

Which leads me to wonder what it might mean to assert that same principle in voting in our civic life. I remember a wonderful, intense conversation with a colleague, a parish priest in my diocese. He was an economic conservative, and I was, as I continue to say, “somewhere to the left of Jesus.” What made that conversation not only possible but meaningful was that we agreed on the ends we wanted to see. We each wanted our society to reflect in some sense respecting the dignity of every human being and doing for others what we would want for ourselves. Our differences were not about ends but about means; and so our conversation was respectful even as our positions were different.

I wonder what it would mean for us to bring that same sensibility to our civic voting. Oh, I’m sure we’ve done that to some extent. We are encouraged to vote according to “what will be good for the children,” or “for the common good” (although like many I seem to hear fewer and fewer voices with any sense that there a “common good” to talk about). What would it suggest to step a bit beyond that and to see the act of voting in civil elections as sacramental and incarnational? Granted, perhaps that’s not something we might bring to civil discourse; but surely we could consider that in our own thoughts and in our own circles.

To do that, though, we might need to take a stand about what are indeed appropriate ends. We have many issues, in the church and out, for which we come back again and again to say that “reasonable persons may disagree.” If we are to say, as I did in that conversation long ago, that reasonable persons may disagree about the means as long as we agree on the ends, then we have to say that some ends are appropriate and some are not. More to the point, we have to say that the Spirit is calling us to some ends and not to others.

For some time now whenever I have found myself in a conversation about ours as a “Christian nation,” I have had to say that I cannot say that. Certainly, I am aware that most of our first national leaders were Deists, and not Evangelical Christians in our contemporary mold; but that isn’t my primary complaint. Instead, I feel that we cannot speak of the United States as a “Christian nation” unless and until we are prepared to incorporate the standards of the latter verses of Matthew 25, the first chapters of Acts, and the first chapter of James. To me, those are ends to stand with, even if we find ourselves arguing about the means.

It seems to me, too, that these ends – serving the widows and orphans and the least among us, and making sure that all have enough – don’t have to be described as explicitly Christian. To act justly and to love neighbor as self are principles we learned from our Jewish forebears. Indeed, care for the poor, a commitment to justice, and doing to and for others as we would wish for ourselves are reflected in every religion I know. Contemporary atheist and agnostic writers are happy to assert their own arguments for these principles.

But I’m a Christian speaking to other Christians, and particularly an Episcopalian speaking to Episcopalians. We share a common language, centered in life in Christ described in the Creeds and the Baptismal Covenant. I feel strongly that we can say that these are appropriate goals for us. More, I feel we can indeed consider that these are the goals to which the Spirit calls us, not only in the Church but in society at large.

So, I joined with my neighbors to vote in civil elections, and with my diocesan siblings to vote for our next bishop. While, that’s done, other civic elections will come – for me, as soon as local elections next spring. We won’t all agree on who to vote for, or what programs or policies to support. However, I will pray we can agree on this: that we are called to make our vote, like the rest of our lives, sacramental, to make manifest in the world the inward call of the Spirit. No, I don’t really expect it will work out that way. Still, I can hope and pray.

Advent Thoughts at the Episcopal Cafe

2010-12-01T09:31:00.000-06:00

My newest piece is up today at Episcopal Cafe. It's a reflection on how one church year ends and another begins. I hope you enjoy it.

And as always I encourage you to look around the Cafe. There's always something interesting to read and to see, and opportunities to respond and share. Look at what my colleagues there have offered, and share with us what our offerings mean to you. We at the Cafe look forward to it.

For Episcopal Chaplains: Info on the 2011 Annual Meeting of AEHC

2010-11-23T21:01:00.000-06:00

Let me share a brief note for my Episcopal chaplain colleagues. Members of the Executive Committee of the Assembly of Episcopal Healthcare Chaplains (AEHC) are making preparations for our next Annual Meeting. Once again this year we will meet in the context of the Annual Conference of the Association of Professional Chaplains (APC), meeting in Dallas March 24 through 27. At this point, it appears that AEHC events will take place Friday, March 25.

Again this year AEHC will sponsor the Episcopal Breakfast on that Friday morning. In light of changes to the APC Conference schedule, we will also incorporate the AEHC Conference Eucharist and the Annual Meeting into the Breakfast. We will also have the AEHC Annual Banquet that Friday evening. Our speaker will be Lee Hogan, Program coordinator for the Anglican Health Network (AHN). He is particularly involved in the Health Microinsurance program that the AHN is piloting in Tanzania. I have met Mr. Hogan, and have heard him speak on this subject. His conviction about the program is contagious. Look for more information as details are made final.

And if you’d like recent information about the Anglican Health Network, check out the website. The October Newsletter is available there, with information about the Health Microinsurance program, and about growth of hospitals in India’s Kerala State, supported by the Church of South India. It’s exciting reading for those of us who are interested in not only knowing about but supporting health ministries across the Communion.

Some Thoughts (Someone Else's Good Thoughts) on Interfaith Encounters

2010-11-22T14:43:00.001-06:00

Years ago I served in a hospital where we used volunteers quite extensively. We trained them ourselves to provide some basic introductory visits and help us identify patients who would need or want more attention from a staff chaplain.

One year an employee expressed an interest in becoming a volunteer. He was a nurse aid working the night shift (11:00 p.m. tp 7:00 a.m.), and a minister in a small storefront church. He offered in no small part to save us staff chaplains some relief with on call. He could, he felt, respond himself, in that he was already in house (at least in the worst hours for us), and provide appropriate care.

That said, we quickly discovered that he wasn’t going to fit our structures. His interest was in bringing patients to Christ, and especially in helping them see their need of Christ in the midst of a health crisis. As such, he wasn’t really showing respect for patients in the terms of their own spiritual journies.

One night we met with him after the training session. Being in Detroit, with the largest Muslim population in the country and also a large Jewish population, we asked how he would care for patients from those communities. “Oh, I’m happy to care for Jewish or Muslim patients. For the Jewish patient, I would speak of Jesus as the fulfillment of prophecy. For the Muslim patient, I would speak of Jesus as a prophet, and also more than a prophet.”

After that, we pretty quickly determined that we couldn’t work with him as a volunteer. We pointed out, too, that as one of the few aids working the night shift, his manager wouldn’t want him running all over the hospital providing spiritual care when that wasn’t part of his job expectations.

So, how is a Christian to approach folks of other religions, and appreciate how we might address those persons? Well, Frederick Quinn, a colleague of mine at Episcopal Café has posted three essays on the subject, and I commend them to your attention. They are:

How should Episcopalians regard other religions?

What does the Bible say about other religions

The path beyond pluralism

I grant you that Quinn is an Episcopalian writing for Episcopalians. However, for me and for my chaplain and clergy colleagues who are Episcopalians, this is a meaningful approach to the discussion. For my chaplain and clergy colleagues who aren’t Episcopalians, I would suggest it is still worthwhile, at least to stimulate thought.

So, give these essays a few minutes. Pluralism is the most common (and much argued) attitude that folks bring to interfaith relations. Quinn’s essays can bring us back to foundations, and as his last essay suggests, see where we might yet go.

The New Game of the Proposed Anglican Covenant

2010-11-17T11:57:00.000-06:00

The words are flying like a game of dodgeball on a playground. All of the players have points to score, and they do their best to combine speed and accuracy. The players twist and turn, trying to avoid being struck. When the balls do hit home, they certainly sting. None of the players really wants anyone else to walk away from the game, to take a ball and go home. At the same time, each of the players is wondering if elimination in the game will become elimination from the game, as if having to leave the field of play also means having to leave the neighborhood.

The topic is the Anglican Covenant. The occasion and the sense of urgency is the meeting of the General Synod of the Church of England, where there will be an initial vote on the Anglican Covenant as proposed. Proponents of the Covenant seem to seek in the same breath to be reassuring and convicting. Opponents seem convicted but certainly not reassured. Godwin’s Law has been cited.

Perhaps I’m too well informed, but I’ve been reading and paying attention. I think I understand several themes in the argument. Opponents say that this document creates new institutions, institutions that have authority at least for signatory churches, and perhaps within the existing Instruments of Communion. Proponents point out (with some merit) that there aren’t new institutions, and that any authority is persuasive and commendatory, and not juridical. Proponents say that the Covenant respects the autonomy and internal structures of signatory churches, and point to explicit language within the Draft. Opponents say that the commitments the Covenant seems to require undermine local constitutional structures in ways that belie the explicit language. Opponents say that the Covenant creates a coercive environment in which one province’s displeasure can stifle Spirit-led innovation, or at least make the cost such innovation excommunication. Proponents say that the Covenant provides ground rules to keep signatory churches in conversation while such differences are discussed, and so prevent excommunication, or at least forestall it as long as possible.

Yesterday, Canon Alyson Barnett-Cowan, Director for Unity Faith and Order for the Anglican Communion Office issued an interpretive comment. That, too, has become part of the game, another ball to be thrown, another target to be thrown at. However, it did include one comment that everyone would agree to, if not to the same point. If we are to comment on the Covenant as proposed, we need to read it.

So, I went back and read it again, looking perhaps for a new way to think about it. That’s when I discovered something I found a bit confusing. It is that the Covenant doesn’t really clarify the relationship between churches of the Anglican Communion and signatory churches of the Anglican Covenant.

Now, that’s not obvious at first. After all, it is titled, “The Anglican Communion Covenant.” Moreover, in the Preamble it states that those who “solemnly covenant together in these following affirmations and commitments” come from the “Churches of the Anglican Communion.” Much of the text is dedicated to describing a common heritage among churches in the Anglican Communion. However, all that notwithstanding, the relationship between the churches of the Anglican Communion and the signatory churches remains unclear.

The thing is, the Covenant as proposed only applies to signatory churches. That’s clear, isn’t it? Churches that don’t sign on aren’t bound by the Covenant. This is clear in Section 4, considered critical enough that it survived three revisions. Certainly, the hope of those who propose it is that all the churches of the Anglican Communion will sign: as paragraph 4.1.4 states, “Every Church of the Anglican Communion, as recognised in accordance with the Constitution of the Anglican Consultative Council, is invited to enter into this Covenant according to its own constitutional procedures.” This clarifies a couple of important things. First, the proposers have decided that participation in the Anglican Communion is defined by the Constitution of the Anglican Consultative Council (ACC) – and, so, not by signing onto the Covenant. So, if the Anglican Communion is those churches recognized by the ACC, signatory churches of the Covenant are something else – churches of the Anglican Covenant.

The next paragraph goes even further in making the distinction:

(4.1.5) The Instruments of Communion may invite other Churches to adopt the Covenant using the same procedures as set out by the Anglican Consultative Council for the amendment of its schedule of membership. Adoption of this Covenant does not confer any right of recognition by, or membership of, the Instruments of Communion, which shall be decided by those Instruments themselves.

Now, this creates an even more interesting distinction. See, while some other churches may adopt the Covenant in response to an invitation to join the ACC (“procedures… for the amendment of [ACC] membership”), it’s also possible to adopt without that invitation. Under what other circumstances would adoption not “confer any right of recognition by, or membership of, the Instruments of Communion?” Adoption that includes joining the ACC would certainly confer such rights.

And, of course, “This Covenant becomes active for a Church when that Church adopts the Covenant through the procedures of its own Constitution and Canons.” So, the Covenant has no meaning, no authority for any Church that doesn’t adopt it; and even for a Church that does adopt it internally (“through the procedures of its own Constitution and Canons.”), adoption in itself does not make the Church a member of the Anglican Communion as defined by membership in the ACC.

This is confirmed by the acceptance of the reverse:

(4.3.1) Any covenanting Church may decide to withdraw from the Covenant. Although such withdrawal does not imply an automatic withdrawal from the Instruments of Communion or a repudiation of its Anglican character, it may raise a question relating to the meaning of the Covenant, and of compatibility with the principles incorporated within it, and trigger the provisions set out in section 4.2 above.

So, just as adoption of the Covenant doesn’t make a church a member Church of the Anglican Communion, withdrawal from the Covenant doesn’t in itself remove one from the Anglican Communion. It would certainly “raise a question relating to the meaning of the Covenant, and of compatibility with the principles incorporated within it,” and perhaps even “trigger the provisions set out in section 4.2 above.” But, those provisions are only applicable for those who have signed the Covenant, and not automatically to the Churches of the Communion

But, what about all those commitments made in the first three sections, commitments that are intended as meaningful consequences of accepting the characteristics of the Anglican heritage as described in those sections? While Anglicans broadly may accept them (indeed, with a few small reservations I can accept them), they are only grounds per se for agreement, or for disagreement, for those churches that sign on to the Covenant. Indeed, the commitments themselves state again and again that they are not specifically Anglican, but are “common pilgrimage with the whole Body of Christ” (1.2.8) and part of “the work of the whole people of God” (2.2.4)

So, we really do have two bodies. We have the Churches of the Anglican Communion, defined as such (at least for the Covenant) by the Constitution of the ACC; and we have this other body of those churches that are signatory to the Covenant. These two bodies are broadly overlapping but not identical. So, at least at the beginning, we have the Churches of the Anglican Communion and the Churches of the Anglican Covenant.

I grant you, it does add to the confusion that the Churches of the Anglican Covenant plan to make use of the Standing Committee of the Anglican Communion as overseer of common life and arbiter of differences. It doesn’t help that in disputes there is consultation with and deference to the Instruments of [the Anglican] Communion, even apparently for churches that have no “right of recognition by, or membership of, the Instruments of Communion.”

However, as I read this Covenant as proposed, it makes an important distinction between the Churches of the Anglican Communion and what I have called “the Churches of the Anglican Covenant.” Under the Covenant, “Churches of the Anglican Covenant” are accountable under the Covenant’s provisions to one another, and even (through respect for the Instruments) to Churches of the Anglican Communion. However, a church of the Anglican Communion (a member of ACC) is not necessarily accountable to a Church of the Covenant (whether or not that church is a member of ACC).

So, for example, we can do a thought experiment. Say that Uganda and Australia sign the Covenant and the Episcopal Church doesn’t. Say then that Uganda raises with Australia an issue regarding lay or diaconal presidency at the Eucharist. Under the Covenant Australia is accountable to Uganda. However, the Standing Committee would consult with one or more of the Instruments; and the Episcopal Church participates in three of them (Lambeth, the Primates meetings, and, critically, the ACC). So, even without signing the Covenant, the Episcopal Church would be at least influential in the recommendations to the Standing Committee, and so (at least possibly) in the recommendations of the Standing Committee to Australia – recommendations that, if not accepted, could lead to discipline of Australia under the Covenant.

I like my games analogy for understanding this, but I want to suggest different games. Bid whist is not contract bridge is not spades. All three games have similar play, but rules that are different in important ways. So, by establishing a new set of rules for those who sign on, the Covenant creates a new body and a new game – a coherent game, certainly, but not one by which players of other, earlier games are bound. There is no automatic relationship, and no automatic accountability, between a Church of the Anglican Communion and a Church of the Anglican Covenant. Canon Barnett-Cowan actually does get this. Look again at her statement,

It is also not true that non-signatories would no longer count as part of the Communion. There will be Provinces which have adopted the Covenant, and there may be (though one hopes not) Provinces which have not. They are equally members of the Anglican Communion, according to the Constitution of the Anglican Consultative Council. The difference would be that signatories will have made a commitment to live in that communion in a particularly enhanced way, and to a process of consultation and common discernment.

So, Churches of the Communion remain Churches of the Communion; and Churches of the Covenant, who may or may not be a Church of the Communion, have decided to embrace external accountability, and all the limitations that might come with it. Is this an “enhanced” way of “[living] in that communion?” Well, no, since member churches of the Covenant are not automatically members of the Anglican Communion; but also, yes, if perhaps in the sense that the penalties for differences within the Churches of the Covenant might be said to be “enhanced.”

Without doubt, and within its own terms, the Anglican Covenant as proposed creates a “new game,” refined from the terms of the “old game” as contract bridge was refined from whist. It creates less two tiers within the Communion and more two overlapping bodies, one accountable within the terms of the Communion (however few and vague they may be), and one accountable both within the terms of the Communion and of the Covenant. Somehow, I can’t imagine that bringing more clarity. Instead, it seems to me to bring less; and if it brings less clarity, then something less than “the highest degree of communion possible.” (3.2.7) And if that’s the result, I don’t see why the Episcopal Church, or any other Church, should be all that interested.

The Coming Medicare Bomb - Again

2010-11-15T21:25:00.000-06:00

In my paper this morning was an editorial by a local physician pointing again to the issues raised by how we currently pay doctors for seeing patients under Medicare. Here is a similar editorial in the Nashville Tennessean by a physician there. Both point out as well that these reimbursement issues apply to Tricare, and so apply to the families of active duty service members.

Of course, receiving 25% less money for the same level of care, the same number of patients and procedures, is a problem for most doctors, who are, as private practitioners, essentially small business owners or participants. While most are all for looking for more efficiencies and other ways to save money, that won’t be enough. So, some doctors are deciding that they will not accept any new Medicare patients. Of course, as our society is aging and living longer, there are more and more new Medicare patients all the time.

These doctors aren’t pointing to new discoveries. These difficulties have been known for a while. Yes, there was a new story in the Boston Herald this weekend; but, there was also a paper ten years ago. In fact, I found a story in the New York Times in 1992. That’s how far back this issue goes.

For a number of years now Congress has been acting every year for some time now to stave off the reductions in reimbursement. They’ve prevented the problem from getting worse, but they haven’t done what needs to be done to make the problem better. That would require reconsidering the way in which these reimbursements are set. Unfortunately, that’s a lot harder than simply saying, “Well, we just won’t allow that change - this year.”

It seems to me that there is a failed premise behind this. The idea is that if Government restricts what doctors get paid, the doctors will buckle down, become more efficient, become more productive, and costs won’t rise. Of course, other costs aren’t controlled that way. So, the doctors have been paying more each year for everything from their supplies to their utilities. They’ve had to pay their employees more each year. They’ve even had to pay more each year to provide their employees with health insurance. At some point these lines have to cross: doctors can see only so many patients, and can provide only so many services, and sooner or later they simply can’t “do more with less.” There simply isn’t anything more to cut. Politicians love to talk about “trimming the fat,” but sooner or later there’s no fat left to cut – and eventually damned little steak!

The doctors whose editorials I cite want folks to communicate to members of Congress. I think that’s a good idea, even if in the current climate one could feel hopeless of actually being heard. I think it’s a good idea to send an email or a fax, or make a phone call – or even send letter by post, despite the fact that security will slow delivery. No, it probably won’t be fixed quickly. But if we as citizens push steadily, it can be fixed.

'Twas the Night Before Convention

2010-11-04T22:59:00.000-05:00

Over the years, there is something I've said many times to students and new volunteers. Eventually, it comes down to this: we pray for the Spirit, and trust our guts. Barring a vision or an audition - and if it's going to come, it would be best for it to come to all of us - that may well be where many of us are for the election of the next bishop.

And after years of that approach, I remain convicted that if I'm praying faithfully, by God's grace my gut is trustworthy.

Thought for the Day Before the Midterm Elections

2010-11-01T14:18:00.000-05:00

Remember, America: there's someone out there who doesn't want you to go vote! Don't give that person the satisfaction!

Preparing for an Election

2010-10-29T23:59:00.000-05:00

Now and again I am reminded of classics of literature, classics that I’m afraid too few folks know these days. They bring us phrases and images that we have used to illuminate our speaking and writing; but without knowing the sources folks don’t really understand the images. The Bible comes to mind, as do the works of Shakespeare.

However, this evening I’m thinking of the fables of Aesop. How many know they are the source of the phrase “don’t be a dog in the manger?” That’s not related to the manger we know best – the one Jesus was born in – but to a story about a dog in comfort who prevented an ox’s dinner. How many know the fables are the source of the phrase “sour grapes?”

Tonight, though, I’m thinking of the frogs who wanted a king. You can read that fable here. Go ahead – it will only take a minute or two.

Now that you’ve read it, you’ll understand the question of whether one would prefer King Log or King Stork. Sure, King Log seems ineffective, even inert; but he won’t consume you like King Stork. King Stork has an energetic, even aggressive program; but King Log will leave your life pretty much as he found it.

In these political times some might assume the civil government brought this to mind. However, I’m thinking about something smaller and more singular. Very soon now I will participate in the election of the next bishop of my diocese – the election of my bishop! It’s not the same. Oh, we vote, and there have been efforts to inform the voters – in this case, the diocesan convention – as well as those the voters will represent in one sense or another. But, it’s not the same. There aren’t campaigns, or at least nothing on the same sort of scale. (I suppose there may have been some “campaigning,” but I’m not in the right circles to know.) There haven’t been “campaign promises” (or, again, I’m not in the right circles).

But the most important way in which it’s different is that we’re praying to be guided by the Spirit. We decide by voting, but we are praying that our voting will conform to God’s intent, and that instead of us deciding who our next bishop will be, the Spirit is using us to express God’s decision.

But, as I often say with patients, it would be much easier if God were better at conversation. I have heard a voice that I thought was God, and circumstances seemed to confirm it; but I haven’t heard a voice about this Episcopal election. Even if I had, I couldn’t be sure anyone else had heard that voice.

So, each of us going to have to think about several questions: what do I want in a bishop? What are the gifts and skills I think a bishop should have for the good of the diocese? I’m not going to answer that definitively on this blog, much less in this blog post. At the moment I’m just conscious of being betwixt and between.

How do I balance my own wishes and the good of the diocese – to the extent I’m able to separate the two? How do I apply in the best Anglican tradition Scripture, Tradition, and Reason? How do I decide among the candidates? Each brings gifts and limitations, and none would be perfect; for, don’t we observe at each such election that Jesus couldn’t get elected as a bishop? So, how do I choose among them, trying to figure out whose specific balance of gifts and limitations best fit whatever needs I focus on?

And so, I find myself wondering whether I would be better off with King Log or King Stork. And of course it isn’t really that straightforward, because none of the candidates is as passive as King Log, nor as destructive as King Stork (or at least we pray not). How do I decide? How? How?

So, remember us in your prayers. I’m trying to hear God, and I believe the other clergy and lay delegates are as well. Remember us, and pray that we might hear clearly for our souls’ health, the health of the diocese, and the health of the Episcopal Church.

Reviewing the Evidence

2010-10-22T11:22:00.000-05:00

I know I’ve complained more than once (say, here or here) about problems with how medical research is conducted and paid for. The problems I’ve occasionally pointed to are known, if not always discussed. The consequences could be quite serious. You have to wonder who’s paying attention.

One answer is John Ioannidis and those who study with him. Dr. Ioannidis of the University of Ioannina in his native Greece is a meta-researcher, a researcher whose expertise and interest is in critiquing the work of other researchers. He is profiled by David Freedman in the latest Atlantic Magazine, as one of their "Brave Thinkers," and the article is well worth reading.

Dr. Ioannidis has combined his expertise in medicine with a talent for math to look closely at what some of his peers have presented and gotten published. When he looked, he had legitimate concerns about what he found. In one review published in JAMA, the Journal of the American Medical Association, he reviewed 49 well regarded studies, 45 of which stated that they had demonstrated effective therapies. He then discovered that 34 of those 45 studies were replicated, and of those 34, 14 were either “wrong or significantly exaggerated.”

While the standard concerns about funding for research biasing the questions, and therefore the results, Dr. Ioannidis suggests another. As Freedman describes it,

Imagine, though, that five different research teams test an interesting theory that’s making the rounds, and four of the groups correctly prove the idea false, while the one less cautious group incorrectly “proves” it true through some combination of error, fluke, and clever selection of data. Guess whose findings your doctor ends up reading about in the journal, and you end up hearing about on the evening news? Researchers can sometimes win attention by refuting a prominent finding, which can help to at least raise doubts about results, but in general it is far more rewarding to add a new insight or exciting-sounding twist to existing research than to retest its basic premises—after all, simply re-proving someone else’s results is unlikely to get you published, and attempting to undermine the work of respected colleagues can have ugly professional repercussions.

We might consider this the “headline bias:” as is commonly said in the news business, “if it bleeds, it leads,” and the sensational is more likely to get attention, even apparently in peer-reviewed journals. Caught between pressure to publish on the one hand, and the general need to fit in with one’s professional peers, both researcher and reviewer can get caught up in highlighting the new and different, even if there’s better information in the replication of earlier studies, whether to affirm or refute them.

The profile of Dr. Ioannidis is an interesting article, and it highlights explicitly the importance of this meta-research. We claim early and often that we want to make our decisions based on evidence. The assumption, of course, is that the information we have is accurate and dependable – that is it, in fact, evidence. If we find it isn’t – when we find it isn’t – we need to take one of those most difficult steps in human experience: we need to take a step back and think again.