Wednesday, May 31, 2006

General Convention 2006: HIV/AIDS

I want to return to the 2006 General Convention, and to actions before General Convention related to health care issues. I have focused on the Report of the Standing Commission on National Concerns so far, because that’s where there is commonly a discussion of health care issues. However, there is another report in the Blue Book addressing a category of such issues. That is the Report of the Standing Committee of the Executive Council on HIV/AIDS.

This year’s report makes an important and troubling assertion: that while the problems, and especially the stigma, of living with HIV/AIDS, continue, the Church has appeared to lose interest, or at least focus. According to the Report,

In response to the mandate to survey HIV/AIDS ministries at all levels of the church, NEAC assisted the committee by providing information from a survey they had conducted, summarized as follows: fewer than ten dioceses have active Commissions on HIV/AIDS. With the help of research done by NEAC as well as Jubilee Ministries, we learned that there are several dozen congregations with some involvement in HIV/AIDS ministry.

This is true despite the facts that,

The expanding character of the HIV picture in this country became even clearer after our consultation with the CDC and our participation at the HIV Prevention Leadership Summit in San Francisco. Alarming statistics have emerged confirming the rapid advance of the disease among men who have sex with men, persons of color, heterosexual women, and most disturbingly, that greater than 50% of all new infections occur among persons age 25 and under.

As a consequence, the Report states,

Through the work of the committee in this triennium we have concluded that the Episcopal Church response to the HIV crisis has lost impetus because of a perception that the crisis has become a “chronic disease.” That this is not the case is borne out by the fact that in 2005 there were more than a million people living with HIV/AIDS in the United States (statistics from Province Nine and Haiti are not available) and more than 40 million worldwide. How then should the Episcopal Church respond to the mandate in the baptismal covenant to “seek and serve Christ in all persons” and to “strive for justice and peace among all people, and respect the dignity of every human being?

Now, in clinical terms designating that HIV/AIDS may be a “chronic disease” simply acknowledges that people are living with AIDS, rather than simply dying of it. I remember clearly when it was otherwise. As a chaplain, I remember that “unknown disease of Haitian men,” that became GRID, and then AIDS. I remember nurses being afraid to care for patients and staff in emergency rooms debating whether they could take care of “those patients,” whether they would or not. And so I am aware of the medical fact that in the American context drugs exist (“available” would be a much more complicated discussion) whereby the greatest percentage of those positive for HIV can live more or less normal lives for long periods of time.

And in that light I fear the Committee’s Report is accurate: since we no longer expect to see people falling out around us, we are no longer terribly interested. This is not to say that no one is interested, nor to suggest that no one cares if asked. However, we once feared AIDS as we now fear Bird Flu, as a few years ago we feared SARS. As a society we are too often moved only by what we fear most and fear now.

And that is indeed sinful. We are standing as the Episcopal Church, as a province of the Anglican Communion, saying that justice for GLBT Christians is also a call of the Gospel. We are standing and saying that we continue to fight racism, that we continue to care for the poor. Yet in our own context – in the American context – AIDS has not disappeared, but has instead continued to plague all those communities.

The Report proposes five resolutions. These include a call for continuing the work of the Committee (which does run somewhat across the resolution of the Standing Commission of General Convention on the Structure of the Church to move the Committee into the revitalized Standing Commission on Health); a call for a program to fight the stigma of AIDS; a call for a Church-sponsored media campaign to raise (or better, perhaps, resurrect) awareness; for a basic HIV training course for all clergy and for most lay leaders in congregations (not unlike the recent Racism training); and a Church-wide survey to identify and map existing AIDS ministries and resource in the Church.

These are worthy steps, and especially maintaining the work of the Committee (whether on its own or as a ministry of the Commission on Health), and raising awareness. I certainly hope that these steps are approved in General Convention. One is at first tempted to say, “This issue is not going away;” but that hasn’t been the problem. The issue certainly hasn’t gone away, but we have. We need to look again, not to return to an old fear, but to return to our commitment to compassion.

Monday, May 29, 2006

Pastoral Confidence in Texas

There’s a fascinating article in today’s news regarding Watermark Community Church, a nondenominational, evangelical church in Dallas and issues of confidence in the conversations between a member and the pastor. You can find news reports on it here and here. Watermark's official statement is here.

Essentially, a member, identified in the court as John Doe, was unfaithful to his wife, identified as Jane Doe. Jane went to the pastor to seek support. Whatever the pastor may or may not have said to the wife, he then proceeded with discipline, following Matthew 18:

‘If another member of the church sins against you, go and point out the fault when the two of you are alone. If the member listens to you, you have regained that one. But if you are not listened to, take one or two others along with you, so that every word may be confirmed by the evidence of two or three witnesses. If the member refuses to listen to them, tell it to the church; and if the offender refuses to listen even to the church, let such a one be to you as a Gentile and a tax-collector. (Matthew 18: 15-17, NRSV)

Following that logic, the pastor saw the couple together. According to reports, the pastor informed church elders. John Doe apparently refused to repent, at least as this church recognized repentance. Therefore, the pastor prepared to send letters to persons both inside and outside the congregation. John Doe stated he had left the church, but the church’s bylaws reportedly stated that he could not leave the church simply to refuse correction. The Mr. Doe then sought a court injunction. According to Watermark's statement, that injunction was challenged and removed. The Mr. Doe and Ms. Roe, apparently the other woman involved, appealed.

For me, as a person in a sacramental church, this raises all sorts of questions, some of which are clearly not understood by the media. For one thing, I can’t fault a pastor for violating the seal of the confessional if the pastor and his congregation don’t accept sacramental confession. I can and do fault him for violating a professional confidence; but if the bylaws do call for acceptance of the system of confrontation in Matthew 18, and if the Does were aware of those bylaws, I don’t know that I could hold him to account. That is, I think this was an inappropriate set up to begin with, but there was a declared set of rules and it appears the pastor followed them.

I think we can question, too, what it means to confront with two or three witnesses. Somehow, sending a note to the elders of the congregation doesn’t seem quite the same. If the elders actually met with the Does, perhaps; but that isn’t reported. And, whence this decision to give this information to persons outside the church? Even if the congregation was committed to the model in Matthew 18, this seems to exceed it.

There is reference in news reports that this was done out of love in an effort to save the marriage. But in what way is Mrs. Doe served by this? After all, she may well experience public humiliation by the revelation. Then, too, isn’t this her story to tell? If she shared the information with the elders, that would be one thing; it is against her that Mr. Doe sinned. But it appears the pastor took the initiative.

How, too, should we understand this concept that one can’t leave a church “to avoid correction?” How would this be enforced? Would they garnish wages to maintain a pledge?

Well, as I said, it’s an interesting case. It would certainly be different in an Episcopal church. There would be grounds for a presentment against the minister for conduct unbecoming and violation of confidence, even if not for violation of the confessional. It’s not that we would deny the process in Matthew 18; but we would certainly follow through differently, making it the responsibility of the person injured with support from the church, rather than a responsibility of the church itself. And, of course, if one or both chose to leave, we would have no desire, much less procedure, to prevent it.

But there are two things here that trouble me. The first is the interpretation of Matthew 18 by the Dallas church. The implication of “let that one be to you as a Gentile or a tax-collector” certainly implies separation, if not outright shunning. However, when we look at how Jesus treated Gentiles and tax-collectors we have a very different result. The incarnate Jesus, reflecting his religion and his culture, might have initially thought of separation. By the end of his ministry, however, he had taken in tax-collectors and had reached out to Gentiles as among those who would enter into the Kingdom “before you [pious Pharisees].” And the resurrected Christ told Peter that he had made all things, including Gentiles, clean, and called Paul specifically to bring the Gentiles in. So, if we are called to treat someone as a Gentile and a tax-collector, aren’t we called to incorporate the person rather than to exclude? This doesn’t imply comfort with the sin, but instead confidence in our salvation in Christ.

And the other thing that bothers me? The note in at least one report that there’s another, earlier similar case of violation of confidence on its way to the Texas Supreme Court.

Saturday, May 27, 2006

Serving God Serving Those who Serve Country

Yesterday, as I was listening to Morning Edition on National Public Radio (if my wife hears me say, “It was on the news,” she knows I heard it in NPR), I was moved by this story. Read it and, if you can, take the time to listen. It is a sample from the StoryCorps project, an oral history project of the Library of Congress. It is portions of an interview of a father by his daughter about the father’s service as an Army Chaplain in Viet Nam. A part of what caught me was a question he had for himself at the time: "Do you have something worthwhile to say to somebody in their last moments?" While the circumstances were not at all similar, I have also been with people in their last moments, wondering myself what I had to say.

This Memorial Day weekend I have am happy to honor my colleagues who are chaplains in the Armed Services of the Unites States. The Chaplains serving in the Army, the Air Force, and the Navy (who also provide service for the Marines and the Coast Guard) faithfully reflect the love and compassion of the faith communities from which they come to the many persons they serve. Many of them will spend at least some of their time as health care chaplains, serving in military hospitals. Many of them are members of the Reserves or of the Guard services, who may be called up on to leave established ministries in congregations to serve multifaith communities in active duty.

They are committed to serving because they see that the need is there, that the people in the Armed Services are particularly in need of support and care. I have had the honor of meeting a number of military chaplains, most (but not all) in the Episcopal Church. None of them thinks that war is a good thing. None of them thinks that the United States is more important than God. But each of them thinks that those who serve us in the Armed Forces are also God’s children, objects of God’s love and concern. Each of them realizes that those who serve us in the Armed Forces have chosen to take on risk and stress for sake of friends and family, and, yes, for us. And so each of them chooses to serve and care for those who take on risks – who are prepared to lay down their lives – for others.

Blessings this Memorial Day weekend to those who serve as Chaplains in the Armed Forces. May they continue to find blessing in honorably serving God by caring for those who serve us.

Wednesday, May 24, 2006

Toward An Episcopal Culture for Health Care: Prayer

I have commented that my discipline as an Associate of the Order of the Holy Cross includes saying Morning Prayer, as best I can, each day. In fact, on days when I am in the hospital I say Morning Prayer in my office. An important part in the Office, as well as in my midweek Eucharist in the hospital chapel, is to pray by first name for each patient in the hospital, as well as for those employees who have requested prayer, or whose particular needs have come to my attention.

I don’t think many patients are aware of this, although it is mentioned in the announcement of the Eucharist. I don’t think many employees are aware of it, although they are informed at New Employee Orientation. I do think it’s very important – on some days the most important ministry I have for patients – that I pray regularly for patients, families, and staff in my hospital.

Which raises this question: what is the role of prayer in an Episcopal culture for health care? That’s both too easy and complex a question. Most would, I think, say that prayer at the bedside is appropriate in health care, regardless of the faith culture, or lack thereof, of the institution. Perhaps; but, then, what would make it particularly Episcopal? Some might suggest that in modern health care prayer may be of personal value, but not of clinical value. Perhaps; but, then, how could that possibly be Episcopal? And what of prayers away from the bedside? If this is an Episcopal institution, when and how should prayer be a part of institutional life?

In an Episcopal culture for health care I would expect prayer for patients would be acceptable and even encouraged. However, there would still be an expectation that the decision whether or not to pray with the patient would lie with the patient and/or the family. (I am making a distinction here between praying with a patient, in the patient’s presence, and praying for the patient outside the patient’s presence.) To pray when prayer is not welcome demonstrates lack of respect for the patient’s own spiritual life (or decision not to have one). It would be a moral violation at least; and those of us who believe prayer has clinical value will also believe inappropriate prayer could do clinical harm, at least to the extent that the patient’s stress and anger would inhibit clinical benefit. Prayer requested by the patient or family, or offered by the practitioner and welcomed by the family, would seem an important intervention to be available in the institution.

And who would be the appropriate practitioner? Should prayer be reserved to religious practitioners – chaplains, clergy, and trained volunteers – or should it be approved from any provider? As Episcopalians we believe that the Laity are the first order of ministry. According to the Baptismal Covenant, all Christians are called to “continue in the apostles’ teaching and fellowship, in the breaking of bread, and in the prayers.” (Book of Common Prayer, page 304) The Outline of the Faith states, “The ministry of lay persons is to represent Christ and his Church; to bear witness to him wherever they may be; and, according to the gifts given them, to carry on Christ’s work of reconciliation in the world; and to take their place in the life, worship, and governance of the Church.” (Book of Common Prayer, p. 855) Might not a Christian surgeon have gifts to pray with a patient before surgery, as well as to do the surgery itself? On the other hand, will that Christian surgeon have the sensitivity – a gift in itself – to recognize the patient for whom prayer would be inappropriate? Some chaplain colleagues are wary of non-trained pray-ers, often out of experiences in which a sincere Christian lay person had fervor but lacked sensitivity. In my own hospital I emphasize that there must be an invitation to prayer, that the person invited must be free to accept or decline (a point of particular sensitivity with respect to the vulnerability of patients and families), and a free acceptance based on the comfort of both parties with the invitation. Rather than discourage such encounters, I hope that I will be informed of such encounters. When they go well I can support and encourage the layperson for spiritual care of patients and families. When they don’t go well, I can address with the layperson the reasons, and teach about appropriate spiritual support. Anecdotal information I have received is that these encounters are almost always welcome. Even those patients who decline the prayer appreciate the good wishes and good faith of the person who offers.

And what of prayer in the life of the institution? Should meetings begin with prayer? All meetings? No meetings? Some meetings? And if only some meetings, which meetings? In some religious cultures for health care, every meeting throughout the institution begins with some sort of devotion or prayer. What sort is determined by the person presenting it, and responsibility is usually rotated among regular participants. In my own hospital, a few meetings related to organizational leadership – meetings of the Board, of the Leadership, and of the Ethics Committee – begin regularly with prayer. They always begin with prayer if I’m present. If I’m not, and I don’t have a substitute, I’m pretty sure they don’t, inasmuch as no one has ever accepted my invitation to participate.

I haven’t chosen to make that an issue. But for an Episcopal culture for health care, perhaps it should be. We say that we express our faith, our principles, in common prayer. If so, in an Episcopal culture for health care should prayer not be a part of the expression of the principles of the institution? In fact this health system, or at least its central referral hospital, does have a semi-official prayer, shared with employees and others on a hospital bookmark. Should it not have a greater visibility, a greater place in the life of the institution?

And if prayer has a place in the institution itself, what sort of prayer? That is, how should prayer in and for the institution reflect the multifaith community that is the institution? This question should be the topic of its own individual post. However, we are all, I think, aware of the controversies regarding whether Christian clergy must prayer with reference specifically to Jesus. My own practice is to pray in God’s holy Name, and to use other Biblical images of God. I know that there is at least one practicing non-Christian in most of those meetings (not to mention all the non-practicing Christians), and I choose to pray in a way that doesn’t challenge that other faith. At the same time I am aware of and sensitive to the concerns of clergy who feel that not to pray in the name of Jesus is to violate their own faith. I will not resolve that here. I only note and acknowledge the problem.

Surely prayer as some place in an Episcopal culture for health care. Prayer is fundamental to our faith, to our relationships with God, and to our ministry. If health care institutions are part of the ministry of the Church, prayer must in some way be fundamental to that ministry as well. There still remains much reflection to be done on how that might be lived out, made incarnate, in the life of the institution and in the experience of patients, families, and staff.

Sunday, May 21, 2006

On Laying Down One's Life

"No one has greater love than this, to lay down one's life for one's friends."

As an Associate of the Order of the Holy Cross (an Episcopal, Benedictine monastic order for men; link in the sidebar), it is a part of my discipline to say two Offices every day. Usually I make Morning Prayer and Compline. Since education is also a part of the discipline as well, I try to observe as many feasts of saints and worthies as I can. And to supplement the Episcopal Calendar and the Lesser Feasts and Fasts, I regularly look at the “Biographies” page on the Mission St. Clare web site. For an information junkie like me, it’s fun as well as informative to look through that list. It draws not only from the Episcopal calendar, but from Lutheran, Roman, Greek, Russian, and Coptic calendars, and occasionally even from the Armenian and Assyrian calendars, as near as I can tell.

There is, however, one note in many of those references that I find jarring. Often in telling the story of a martyr of the early Church, some of those remembered, or at least their stories, make a great deal of looking for opportunities to die. Witnessing to the death – witnessing by death – seems less a hazard of being a public Christian than some sort of competition. I’m sure this is more the way the stories are told than the actual history might show; but some of them seem more to be seeking to die for the faith more than to witness to the faith, even if they die for it. The dying seems to become as important, or more important, than the testimony.

Now, as I understand it, the Church long ago decided that was bad theology. At the same time, it was not really all that big a surprise. Jesus died for us, and many have been willing to die for faith in him. It’s not really all that big a surprise that some should put the cart before the horse.

But, it does make it hard for us, doesn’t it? After all, if that is the example of the greatest love, what does that mean for us who aren’t called to it? True, Christians die in many places around the world simply because they’re Christians. But we don’t live in those places. We aren’t called to testify to our faith in the face of those risks. And, honestly, how many of us would if we were faced with it? We hope we would have that kind of faith, that kind of courage; but we can’t be sure if we haven’t been tested. And what if we were tested and failed?

I think that reflects some confusion. You see, dying on the cross was certainly critical, but it wasn’t the only way that Jesus gave of himself to the disciples, and to us. Each day he spent preaching, he was giving of himself. Each time he laid hands on someone to heal, he was giving of himself. Each time he taught the disciples about the Kingdom, he was giving of himself. In a very real sense, he was laying down his life in those acts every bit as much as he would on the cross. Sure, it was not so dramatic; but it was certainly important.

So it is with us. We worry that to give one’s life for another reflects some single, dramatic act, some glorious and tragic death, for the good of another. However, if we give our time to another, that time is gone: we can’t get it back. The hour spent reading to a child instead of for oneself is a piece of life that can never be taken back. Time moves on for us, and we don’t get to reclaim it. With every choice, every step taken to serve another we give a piece of our life, of our time, that we can never recover. With every gift given, every act of charity, every act of compassion and love, we give away pieces of ourselves, pieces of our lives. Certainly, those acts are not dramatic. Indeed, we may not even think about them. But with every act of kindness, whether to friend or family or stranger, we lay down our lives, piecemeal, for others.

Christ laid down his life for us. Certainly, he did it on the cross; but he also did it with every healing and every miracle and every word about the Kingdom and the love of God. Some of us – blessedly, few of us – may be asked to lay down our lives in death, in a single and significant sacrifice of life for another. But we all have the opportunity to lay down our lives for others in the other ways that Jesus did. “No one has greater love than this, to lay down one’s life for one’s friends;” whether that’s done in one dramatic moment, or one day, one hour, one moment at a time.

Saturday, May 20, 2006

"This is my commandment...."

"This is my commandment, that you love one another as I have loved you.”

She sat in my office one afternoon. She shared with me her story. If it was not the most sordid story I had heard, it was certainly sordid enough. She had a past: a difficult and painful past. A past filled with what she had been assured was sin. A past that filled her with shame.

She shared with me that she had, and knew she had, “low self esteem.” In her case this was understatement. “I try to be a good person, but I always hear, ‘But….’” But, it’s not good enough – she’s not good enough.

As I listened to her history I was quite conscious of mine. It was not like hers. I had not suffered anything close to what she had. Still, I was conscious of my history. Where I work, that has a particular importance. I am a chaplain Board Certified by the Association of Professional Chaplains (APC; link in the sidebar). Two of the Standards of APC to which I am responsible are to “identify one’s professional strengths and limitations in the provision of pastoral care;” and “articulate ways in which one’s feelings, attitudes, values, and assumptions affect one’s pastoral care.” To meet those Standards one must have explored one’s own history. More than that, one has to have learned from one’s own history. (I have found over the years that ministers who have not learned from their own pain are at best useless, and at worst harmful.) Indeed, when I was Certified the Standards were more explicit on that very point, referring to understanding how one’s own history affected one’s practice of pastoral care. And so, while my history was not hers, I was aware of my history. And when I told her that I knew something about shame in adolescence leading to self-destructive, self-negating choices, I could do so with integrity.

My own history? Well, let’s just say that nice girls wouldn’t go out with me. When I was in seminary I went to a Christmas party while back home on break. Those present were friends from high school and college. I was approached by a young woman I did not know who asked me, “Are you the real Marshall Scott?” I answered that I was the only one present, and asked why that was important. She said, “I heard that Marshall Scott decided at 14 that he would be a minister, and so decided he would experience every form of sin so that he could understand it.” Friends sprang to my defense. My answer, however, was, “I have not experienced every form of sin. I have experienced a number that I do not recommend.”

I remain conscious of my sins, whether I can “recommend” them or not. I’m not obsessed with them. I have come to some understanding of, appreciation for, grace. I have come to that myself through times of fear and anger and anxiety, long nights in despair, screaming at God, wishing that God was better at conversation. Relevant to this encounter and others like it, I have come to that through times when I leaned heavily on the faith of the Church, the faith of my sibling Christians, because my own was weak. When I could not imagine God’s grace for me, there were those who could, primarily out of their own histories. And when I could not believe, I was sustained knowing they could. And this was an expression of Christ’s love for me: that I should be touched, sustained, by members of his Body, members who knew that he believed, even when we could not.

She sat in my office and told me her story. And a large part of her story was how she had lost faith – indeed, had had it burned out of her, in part by harmful church people, and in part by her own shame. “I don’t know how to pray. I don’t know that God does care – that God can care – for me.”

And I said to her something I have said to others. I said, “I believe that, with all you have experienced, you are a beloved child of God. I also understand that you can’t believe that right now, that with all you have experienced that doesn’t make sense. So, I will not ask you to believe it. But, can you believe that I believe it? Because I do believe it. I want you to hold that, shelve it perhaps in the back of your mind. That way you’ll have it; and when you can’t believe that God loves you, just as you are, you can recall that I do. I believe that God loves you; and when you can’t believe that, then believe in me, and believe that I do.”

Each of us, if we’re honest, if we’re prepared to acknowledge our history and learn from it, will acknowledge times when we don’t believe. In those times, it is not the content of the faith that can carry us. It is the experience of the faith lived, of the love shown, by those who do believe. When we can share our own experiences of grace, our own experiences of the God’s love in the midst of our own shame, we can offer that experience to others. And if that means not simply sharing another’s faith, but carrying it for them, well and good. After all, that is one of the ways in which Christ has loved us.

Wednesday, May 17, 2006

Of Jesus and Blackberries

I have been out on the garden this evening. I should clarify: my wife loves to garden. I love to harvest. The cost of the opportunity to harvest is the grunt work in the garden.

That said, there are parts of our garden that are entirely mine. Our back yard, in what was a suburban neighborhood 75 years ago, isn’t big, but it is packed. In that space are blueberries, blackberries, raspberries, and a peach tree. Those are mine. I will help my wife plant and care for beans and tomatoes and eggplants and peppers, both sweet and hot (and a little exotic); but those are hers. The berries and the fruit tree are mine.

Which gave me a certain perspective on the lessons for this past Sunday (RCL) on the vine and the branches. Blackberries were particularly apt; especially the thornless ones (yes, I have both thorny and thornless) because they’re really more vines than stakes. Blackberries only bear fruit on second year wood. That is, a new stake or vine grows in year one, puts out leaves, and grows, but it doesn’t bear fruit. It will winter over, and then bear fruit the second year. And having borne, it will not bear fruit again. Those canes or vines may well put out leaves again, but they will not flower or bear.

That puts me to work in September. (I could perhaps do it sooner, but that’s when I usually get around to it.) I have to cut out the old stakes that bore this year and tie up the new stakes that grew this year. I also have to prune them back, lest they grow too high or too far to be managed in the space I have. There is a particular cost to this. The thorny blackberries exact a cost in blood – never much, but always some. I have become quite deft in threading a hand back among the stakes and vines to reach that berry at the very back, but one way or the other – reaching in or drawing out – I will brush a thorn and be pierced. I have become pretty good as well at tracing each stake, each vine, back to the point where it breaks ground, so as to remove it completely; but they don’t want to come. Whether I try to take them whole or cut them into segments, they will grab or pull or tangle, and they will get a piece of me.

Now, Jesus was talking about viniculture – grapes grown for wine and for the table. I have also lived with grape vines, both wild and domesticated. They take work if you want to get good harvests, year after year; but they don’t bite. It is easier, too, to track each growth tip back through its branch to the vine stock. Whether natural or grafted in, the branch tracks back to a visible vine.

But blackberries are different. The vine, in that sense, is underground. Each year’s new stakes and new vines break ground individually, or grow off a root that barely breaks ground itself. They grow prodigiously – often eight or nine feet in the first year. They tangle and intertwine, apparently competing for the sun, and yet developing a lattice that is self-reinforcing. Often I don’t even have to use twine for the loose ends. I simply entangle them in a way that allows one to support another. And, as I have said, they certainly bite. To love blackberries requires a willingness to take the pain.

Jesus was talking about viniculture. But I wonder whether he would have spoken of blackberries had he been talking today. There are some differences that wouldn’t work, perhaps. And I will admit that I don’t find at all comforting the thought that it is the canes that have borne, and will never bear again, that have to be pruned away entirely. At the same time, the isolation of each stake, even as all the stakes entangle in a way that becomes mutually supportive, sounds a lot like our denominationalism. And we are certainly arrogant, seeking to grow prodigiously as if the sun itself could be our own. But the best part, or at least the most apt, is the fact that to love the fruit, to gather and claim it, takes a cost in blood – that is too close for comfort, and entirely too close to ignore.

“I am the root stock, and you are the stakes; and as troublesome and thorny as you can be, to gather you in I am willing to bleed.” It’s not the same; but it sure has a certain ring to it.

Tuesday, May 16, 2006

General Convention 2006: Medical Futility

The Blue Book for this General Convention, in the Report of the Commission on National Concerns, includes a reference to medical futility. The report states, "many hospitals and some states have adopted a relatively new policy of health care called “Futile Care.”…. It would be wise for patients and loved ones to inquire if their state or hospital has a Futile Care Policy before seeking care.”

The Commission has a point. Some of us would say this isn't so new - until we remember that the entire field as we understand it is new, less than a generation old. For much of the public, informed largely by the news media (and by the hype media that masquerades as news), this is indeed new, or at least not fully thought through. It is poignant right now. Saint Luke’s Episcopal Hospital of Houston, a ministry of the Diocese of Texas, is currently involved in such a case, as is the University of Kansas Medical Center in Kansas City, Kansas. Each institution feels close to me – too close for comfort – if for different reasons.

"Futility" is the word that comes up in end-of-life care when the providers feel that any care that might be offered will not provide the patient anv benefit. The concern expressed in the report is for the protection of the patient: “In general, Futile Care Policy (sic) means that a hospital can make a decision regarding the likelihood of a patient’s recovery, and may conclude that further treatment is futile. That decision can then be conveyed to the patient’s family. If such a policy is in place, the hospital has the right to discharge that patient and it is not a policy that would be advertised.” The concern is, of course, that the hospital is making this decision, and can act, without consultation with the family. More pointedly, there is concern that physicians and/or hospitals can make a decision to withdraw care, allowing the patient to die, without consultation with the family, and regardless of the wishes of the family and, possibly, of the patient.

And why would hospitals or states make this decision? The report in the Blue Book states that this is "fueled by the rising costs of medical care," and this is certainly not irrelevant. Costs are rising; and while we do not like putting a price on a human life, resources are limited, and those spent on one patient who cannot benefit cannot simply be recovered for a patient who can. But it is also, I think, fueled by a conviction that prolonging physical function for a patient beyond a point of meaningful recovery and life is a violation of the patient's dignity, if not actually cruel.

In the medical ethics literature, this is a difficult subject. There does not seem as yet to be a consensus in medical practice about how to determine that care is futile. A policy paper of the American Medical Association describes a process for addressing issues when care is futile, but does not set a standard for futility. Lawrence J. Schneiderman, MD; Nancy S. Jecker, PhD; and Albert R. Jonsen, PhD, scholars of the University of California at San Diego and the University of Washington, proposed a standard for determining futility in the Annals of Internal Medicine (1991 abstract here; 1996 article here) that had both quantitative and qualitative aspects, and that made the important distinction between an intervention’s effect on an organ or system, and an intervention’s benefit to the human patient. The proposal is interesting, and has apparently been a cause for professional discussion; but it doesn’t seem to have been accepted by the profession, much less recognized as a standard of care.

The Episcopal Church has not spoken to futility as such. General Convention resolution 1991-A093 provides the most thorough set of standards for consideration of prolonging care or withholding or withdrawing care at the end of life. At the same time, 1991-A093 helps us see the shift that we are concerned about. It speaks clearly to the right of a patient, or of a patient’s surrogate decision maker, to refuse care at the end of life, to respect a patient’s “right to die.” It even includes a reference to state laws on the subject:
“We therefore express our deep conviction that any proposed legislation on the part of national or state governments regarding the so called "right to die" issues, (a) must take special care to see that the individual's rights are respected and that the responsibility of individuals to reach informed decisions in this matter is acknowledged and honored, and (b) must also provide expressly for the withholding or withdrawing of life-sustaining systems, where the decision to withhold or withdraw life-sustaining systems has been arrived at with proper safeguards against abuse.”

However, the concern at issue now is precisely the converse: does the provider, the physician and/or hospital, have the right to withdraw care, based not on the patient’s wishes expressed directly or through a surrogate, but based rather on clinical criteria and a sense of whether the patient can actually benefit from the treatment. This is not a shift from one’s “right to die” to some sort of “obligation to die,” although some will want to make it seem so. In fact we know that until the Kingdom comes we will all die, and that for all of us at some point there will be nothing more beneficial that can be done. What is still at issue is that understanding of “benefit.” If the patient is brain dead, as documented by neurological and blood flow studies, is ventilator support really of benefit? This is why the distinction between “effect” and “benefit” is so important. The ventilator has an effect: tissues remain oxygenated, and continue after a fashion to function. However, it will not change the overwhelming damage to the brain that means we will never get this person back. We acknowledge in that instance that the patient’s surrogate can withdraw that care. We acknowledge that the physician can decline on moral grounds a request to continue care, and transfer that patient’s care to another physician. In fact we acknowledge that brain death is legal death, and no care is required for the dead.

And what of the case where the patient, in the best experience of physicians, will not recover, though not yet dead, either by brain death or cardiac death. This is where we begin to think about futility. Can the physician acknowledge that there is no further intervention that will benefit the patient? Benefit to what standard? Can the patient or the patient’s surrogate believe that medical opinion, now that it has moved from the abstract to the very personal? What does the family believe, and hope for?

There is still guidance to be found in 1991-A093. It says,
“there is no moral obligation to prolong the act of dying by extraordinary means and at all costs if such dying person is ill and has no reasonable expectation of recovery;” and

“We encourage health care providers who make it a policy to decline involvement in the termination of life-sustaining systems to communicate their policy to patients or their surrogates at the earliest opportunity, preferably before the patients or their surrogates have engaged the services of such a health care provider;” and

“Advance written directives (so-called "living wills," "declarations concerning medical treatment" and "durable powers of attorney setting forth medical declarations") that make a person's wishes concerning the continuation or withholding or removing of life-sustaining systems should be encouraged….”
These statements are fully consonant with the report in the Blue Book for 2006, as is the concern about the actions of governments on this issue.

At the same time, the change in focus is important. Moving from protecting a patient’s right to die to establishing standards for withdrawing care potentially without the participation of the patient or surrogate indeed represents a significant shift – one to which the Church does indeed need to respond.

Friday, May 12, 2006

This Anglican Family

In preparation for the General Convention, we’re presenting open forums (fora?) to discuss issues, to inform parishioners, and to invite questions. We’re also doing some preparatory reading, and especially the Fall 2005 edition (volume 87, number 4) of the Anglican Theological Review. This edition is specifically a collection of articles in response to The Windsor Report. These articles were written by theologians, academics, bishops, and parish clergy from the Episcopal Church, the Church of England, and the Anglican Church of Canada. Some I agreed with and some I didn’t. Some were more persuasive and some less. Events may have overtaken the value of the collection, but I don’t think that’s happened yet. I can certainly recommend reading it.

The article I found most persuasive and useful was the article “An Opportunity for Grace in the Anglican Communion” from Bishop William Gregg of Eastern Oregon (abstract here). Unlike most of the other articles, Bishop Gregg did not look at the causes of the current controversy so much as at the way the controversy is being lived and acted out. His was not an examination of an issue at debate. It was instead an analysis of the way we are working this out using the family systems theory of Murray Bowen and Edwin Friedman. Friedman is especially well known for his efforts to apply family systems theory to congregational life, and Bishop Gregg is using these tools in the same sense here.

I found in most helpful precisely because it doesn’t try to assert a position within the controversy as much as it suggests how we might understand our own behavior in the controversy and take a step back. Other articles examine what koinonia might mean for us theologically. This article looks at how we might try to live koinonia functionally. Other articles asserted that one issue or another was most important, or that one position or another was most worth arguing. They were all interesting, but none offered me much of a sense of hope. This was the one article that I found could encourage me that this argument was worth seeing through for the opportunity to stay in relationship. (Perhaps the editors of ATR agreed with me on this. This was placed as the last article in the collection.)

At the same time, that position certainly reflects some bias on my part, and something of a peculiarly Euro-American mindset. The article looks at the Communion as a family in function, and not simply in metaphor. In that light the miscommunication and arguments are evidence of dysfunction. The dysfunction can be addressed directly, respecting all individuals and relationships in the family, with changes to more appropriate, healthy behavior – all of which is clinical language which means much the same as the instruction from my childhood, “We can all get together if everybody will just act right!”

And that, of course, brings us back to all the other articles. So many voices out there, so many opinions, aren’t interested in better communication. They aren’t interested in hearing others better or respecting other opinions. That isn’t the sin of one party alone: both poles of this debate have demonstrated this failing. “I’ll know we have better communication when you find my position compelling,” doesn’t really get us any farther.

In addition, the therapeutic framework used may not be of interest to those in the Global South. I’m not suggesting they can’t understand it; I’m sure they can. I wonder, though, whether it’s familiar to them. I wonder, more, whether it’s useful to them, in the sense of offering a tool, a mindset, that will be applicable in those settings. We have asserted widely, and The Windsor Report itself notes, that we live this faith in very different contexts. I have been taught to appreciate the therapeutic approach in this context. I cannot assume it will readily translate into another.

Still, it is, as I said, the one article that gives me hope, or at least some encouragement to stick the argument out. It seems to me of all the articles the one most in the true spirit of Windsor, interested in how we can maintain the highest level of communion even with all of our differences. It’s worth the time to read (use the library, or interlibrary loan, because I can’t seem to find it available on line), and to consider. Other articles see this current controversy as an opportunity to clarify one issue or another. This article sees this controversy as an opportunity to build healthy relationships, the sorts of relationships that can give real substance to our experiences of communion.

Tuesday, May 09, 2006

Baptists and Episcopalians

I’ve been thinking about the changes in the Church (which may well have been held at bay [no pun intended], at least temporarily by the election in the Diocese of California). I have begun to think about what has been happening in the Episcopal Church and the Anglican Communion in light of what has happened in the last generation in the Southern Baptist Convention.

Now, as I sometimes say, I grew up breathing Southern Baptist air. I grew up in East Tennessee, where the Southern Baptists so outnumbered everyone else that I had to move away and discover in references on American religion General Baptists, American Baptists, and even Two Seed in the Spirit Predestinarian Baptists (yes, while small, they do exist). So I was not about to ignore the movements in the Southern Baptist Convention beginning in the 1980’s. A small, committed, organized group of clergy who were committed to seeing Scripture as “verbally inspired, inerrant, and infallible,” began to work to take control of the Southern Baptist Convention, and of those institutions supported by the member churches. Gradually, through skill and planning, and good (and entirely legal) use of the political structures of the Convention, they began to build majorities on the various committees of the Joint Program. (For reference, all Southern Baptist churches are congregational. They meet in Convention, and together support the Joint Program and its various activities.)

They first began to concentrate on the colleges and seminaries. Gradually, one by one, membership changes on Boards of Trustees moved them steadily toward a more Biblicist position. Those Boards then moved those seminaries toward a more Biblicist academic culture. Now, some undergraduate schools, having large student bodies, dependable tuition income, and independent endowments, were able to stand for academic freedom and prevent radical change and loss of control. Baylor comes to mind. However, the seminaries were not able to do so. New statements of faith were formulated by Boards, faculty were required to sign them and to conform, and those who refused were fired. But success in this effort was terribly important: the seminaries would shape the new clergy, who would then maintain the Biblicist position and perspective in individual churches and in the Convention.

This was a more radical change than many thought at first. Frankly, many, many Southern Baptists in the pew were (and are) likewise committed to a belief in the literal interpretation and inerrancy of Scripture. Many who entered Southern Baptist seminaries were from that background.

But the Southern Baptist heritage was broader than that. The official position had long been that while most Southern Baptists were indeed evangelical and conservative, and many were literalists, only God could see into the heart and only God could judge an individual’s faith. With that latitude, Southern Baptist seminaries had always pursued the best Biblical scholarship and theological education. Now, students who were literalists were neither excluded nor condemned; and many graduated with those sentiments intact. But they had been exposed to that scholarship and understood it; and they did not automatically condemn those who disagreed with them. If there was one thing Southern Baptists prized, it was freedom of belief, and their own freedom from “Baptist orthodoxy.”

All of that has ended, of course, as the last several editions of the “Baptist Faith and Message” have become not only Biblically more conservative and literalist, but also more a confession, a required statement of belief demanding conformity. In my own field of chaplaincy that has led many chaplains who had been Southern Baptist to seek the Spirit, and their professional endorsement, in other Baptist bodies, such as the Cooperative Baptist Fellowship and the Alliance of Baptists. I understand from them that this has been true as well of some congregational clergy. That which Southern Baptists had fought hardest against seems to have become the fact on the ground: a Baptist orthodoxy described in a confessional document.

To some extent all this sounds familiar. The move of American culture to a more conservative position began a generation ago, with the election of Ronald Reagan as President. The movement expressed its presence and its energy in the Contract with America, put forward by Congressional representatives. It became consolidated in Karl Rove’s expectations of conformity from K Street lobbyists. It hasn’t simply sprung up overnight.

It hasn’t in the Episcopal Church, either. Even after the changes in canons in 1976 that allowed women access to all ordained ministries of the Church, some bishops will not consider ordaining them. Even after the acceptance of the current Prayer Book in 1979, the Society for the Book of Common Prayer has continued to function. Even though the initial splinter churches to leave the Episcopal Church fared poorly, organizations like Forward in Faith offered them a voice. The Anglican Mission in America is not itself new anymore. And while these preceded the American Anglican Council, and are separate, they have been in conversation, finding common cause and possibilities of joint effort. Now, none of this has been secret, the notorious Chapman memo notwithstanding. We have simply not been paying attention. Or, and this is perhaps more likely, our willingness to include everyone called us to let this happen with little response – the very inclusiveness that some now hold against the majority in the Church.

Now, I don’t think the same thing can happen in the Episcopal Church that happened in the Southern Baptist Convention. We are not so purely democratic and majoritarian as the Convention, however we may sometimes be perceived. Our fear is less of orthodoxy and more of the tyranny of the majority. Nor are we congregationalist, however some of us may act. We have the Book of Common Prayer and the acts of General Convention to guide and to express our faith.

But we need to recognize that this is not a new phenomenon. It has been building, within our sight, for some time. We should not be shocked to see it now.

Thursday, May 04, 2006

More on Health Care: Convention 2006

I have been reading further in The Blue Book, the compilation of reports and resolutions from the commissions, committees, agencies, and boards (CCAB's) of the General Convention. I have found some further items of interest to those of us concerned with issues of health.

Those I noted today are in the Report of the Standing Commission on Liturgy and Music. This is one of the larger reports, and much of it, while of general interest, does not relate to specific interests we face in health care ministries.

However, there are some portions of the report that may well be useful to us. I note first a detailed report from the Committee on Rites of Passage. It includes a theological discussion and guidelines for structuring such rites. Potentially even more valuable are specific prayers and rites for a wide variety of life transitions. These are divided according to stages of life: transitions of Childhood, Young Adulthood, Midlife, Elders, and Remembering the Departed. There has been a clear effort to recognized the sanctity of all of life. Here, for example, is the prayer for Moving from a Crib to a Bed, with rubrics for use:

The new bed may be made up with the child’s help. Members of the household, including the child, may move in procession from the crib to the bed with pillows, blankets, stuffed animals or other objects regularly part of the nighttime ritual.

Good and loving God, your watchful care never slumbers, and you give gifts to your children even as they sleep. Thank you for bringing us all to this day into which N. has grown in your protection. Give her blessed rest wherever she lays her head. Keep her well and fill her dreams with hope. Awaken her every morning to the sureness of your love with joy and courage for the day at hand; through Jesus, our Savior and Friend. Amen.

For young adults there is a Rite of Passage for a Significant Birthday, and a Rite for Celebrating an Engagement (The Blessing of a Betrothal), with recommended lessons and hymns. There is also a separate Rite for elders for a Significant Birthday, as well as a rite for Farewell to a Home.

The prayers for Remembering the Departed will, I think, be of particular use in health care, although they are not specifically written to that end. There are prayers to remember the departed person at one week, one month, and one year. There are prayers for Coming Home Without a Departed Loved One, and for Giving Away Belongings. This is the prayer On Grieving a Violent Death:

Lord of Life, you trampled death under your feet so we might come alive in your eternal light. We remember before you our beloved N. In our anger and confusion, we need your help to find our way. When your own child, Jesus, suffered violent death, you acted through it to redeem the world. Help us live into that knowledge as we remember that N. now lives because of that great gift of your love. Help us release him to you. Show us that your hand has dried his tears and let us glimpse his joy in your face. Grant us strength and the spirit of healing and peace so that we may labor for your just and peaceable kingdom where all your children live in safety and fulfillment, through Jesus Christ our Lord. Amen.

There are three prayers offered for the Violent Death of a Child.

With these reports are resolutions to add these materials to the next revision of The Book of Occasional Services. In addition, there are resolutions to develop editions of the Daily Offices of Morning and Evening Prayer in the inclusive mode of the Enriching Our Worship series.

One disappointment in the Report is the review of Committee on Reproductive Loss. There is an extensive list by title of the prayers and rites that have been in development. This includes reference, among others, to prayers Before and After a Difficult Decision; for Miscarriage, Stillbirth, and a Child who Died in the Womb; and Following Termination of a Pregnancy. There are Litanies of Lament and Hope, a Rite for Pregnancy Loss, and Prayers Surrounding Adoption. Other Prayers include those for Hysterectomy, Mastectomy, a Difficult Pregnancy, an Unwanted Pregnancy, and a Child with Special Needs. However, this is only a list by title. The work itself was not ready for publication in The Blue Book. We can hope that it will be available in draft at Convention.

As Episcopalians we believe we are shaped by how we worship and how we pray: lex orendi lex credendi (the rule of prayer is the rule of faith). I think these new prayers and rites, if passed, can be useful to us as Episcopalians in expressing our faith and feelings in these passages of life. I think they can be particularly useful to us in health care ministries, offering us new options, new tools, in helping people express faith and feeling in the midst of transition and crisis. I certainly hope they pass. And whether they pass or not, we may well want to review this report, to make use of those prayers that can help us care for those we serve.

Tuesday, May 02, 2006

Slow and Steady Wins - Doesn't It?

Every month I orient new nurses and other clinical staff to our hospital’s policies and procedures related to advance directives, organ and tissue donation, and patient rights. In the process I discuss just who speaks for the patient, and how we respond when the patient has lost the capacity to make decisions, and the family on one hand and the medical and clinical staff on the other see things differently. “It is always worth the effort,” I say, “to seek consensus between the family and the clinical staff. If that takes an extra day in ICU, it’s worth it. If it takes more time educating the family about what the staff are seeing, it’s worth it. It’s good for the patient, and good for the family, and good for you; and I’m convinced it’s good for everyone’s souls.”

What brought that to mind has been reading the various responses to the Report of the Special Commission on the Episcopal Church and the Anglican Communion. In one sense, I suppose the best thing to be said about the report is that folks at both ends of the spectrum find it inadequate. You can start your own review at Thinking Anglicans (link in the sidebar), from which you can link to a lot of other sources.

But specifically I was struck by the repeated reference in the Report to seeking consensus. The word occurs sixteen times in the Report and the related Resolutions, not counting the reference to consensus fidelium quoted from the Windsor Report. Now, it’s not a surprise that the SCECAC Report should refer to consensus. The Windsor Report, to which this is a response, does so as well (although not as extensively and primarily to point out that consensus does not exist. The Windsor Report spends a lot more time in "discernment;" but that can be the topic for a different post.). But focusing on consensus highlights the differences between the two poles in the difficulties in the Anglican Communion.

Working toward consensus, and particularly governing by consensus, is a religious practice. It is the primary way of doing business of the Society of Friends, the Quakers. It has recently been adopted by the World Council of Churches as that organization’s way of reaching decisions. You can read more about that here and here.

Essential to understanding consensus is appreciating that the decision process is not over until it’s over; and no one is left out. That may mean that decisions take a long time. It may mean that some will continue to disagree, but will accede to the larger group because they have been thoroughly and fairly heard. It may mean that when a group cannot reach consensus they choose to live with that, and to announce simply that consensus is not currently possible. It does mean everyone is heard fully and respectfully. One significant difference from democracy, a difference that I believe is an advantage, is that it works against the “tyranny of the majority” – the possibility that a majority may use agreement to justify persecuting, marginalizing, or excluding the minority (sound familiar?).

The Episcopal Church has consistently taken the position that consensus on human sexuality is desirable, and that until consensus is reached everyone needs to keep talking and to keep listening. The Windsor Report, overall, seems to say much the same thing. That, at any rate, seems to be the consequence of continuing to insist on the listening process.

But majorities can be very uncomfortable with consensus; and this is even more true of minorities who feel that they can link themselves to a majority. The Global South primates are a minority (if a large one) among the total primates of the Anglican Communion, and a minority in economic strength; but they are quick to proclaim their majority at the 1998 Lambeth Conference, and in numbers of believers. The AAC/ACN folks are a minority in the Episcopal Church; but they are quick to attach themselves to the majority they see as claimed by the Global South primates, and within the larger American context. The Episcopal Church and the Anglican Church of Canada are a minority within the Communion; but they cherish the Anglican Consultative Council and the majority there that wants to continue the Communion, as well as the majority of primates who have not severed relations (yes, I’m making a distinction between “broken” and “impaired” communion, but then so did the provinces that chose to use one of the other of those terms). GLBT members of the Episcopal Church are a minority, but hold fast to the majority in the General Convention of the Episcopal Church in 2003.

I fear, too, that all of these groups fear a consensus process, at least to some extent (and the more “fear-based” the position, the greater the fear). They fear the time it will take, during which their vulnerability (sometimes perceived, sometimes very real) continues. More critically, I think they fear that if there is a true consensus process, and everyone is fairly heard, those “other folks” may actually make some sense. They fear actually having to respect one another. There is a much greater sense of control when a democratic process ends with me in the majority. If I actually make the effort to listen in a consensus process, I might actually hear something that confronts me. I might actually be changed.

I have less hope than I once had that all of this will be resolved through a coherent process. I think we can seek a listening process and work for consensus; I think it’s worthwhile. I fear, though, that issues of fear and control will win the day in the short term, and that the Communion will be significantly changed, if not broken altogether. And perhaps that is God’s will. Still, if we are to seek to be one Body, we cannot simply dispense with the efforts for reconciliation and consensus. It is, we believe, God’s will that we all may be one. It may not be reached by a consensus process; it cannot be reached through efforts of fear, control, or expediency.