Monday, October 29, 2007

Leadership From the Top

Episcopal Life Online is reporting today on the recently concluded meeting of the Executive Council of the Episcopal Church. I imagine much will be made of statement in response to the Draft Anglican Covenant, and perhaps of the response to the recent statement from the September meeting of the House of Bishops. However, I wanted to highlight a later note, something that says something not only about our Presiding Bishop, but also about the Episcopal Church.

The report on Presiding Bishop Katherine Jefferts Schori’s remarks to Executive Council includes this paragraph:

Jefferts Schori also asked that the Council consider whether there is a way to conduct a mutual ministry review of her work. She suggested that such a review would be a way to ask the question of "how is this office reviewed and challenged."

The link in the paragraph is to a report prepared jointly by the Episcopal Church Foundation, the Office of Ministry Development, and the Church Deployment Office, and, as the report says, “Many Diocesan Representatives.” The report discusses the meaning of mutual ministry, purposes of review and evaluation, and procedures for such a review.

There is a section specifically titled, “Ministry Review for Designated Leaders.” It includes principles for preparation, and for the review itself. It calls for the review to include all orders of ministry from the “congregation,” and also participation of all the “designated leaders” of the “congregation.”

What I think is most important, and most challenging, about this request from the Presiding Bishop is her willingness to be accountable for her work for the whole Episcopal Church. We might debate how well we’re pursuing “mutual ministry” as a whole Church, but in many places it has been an important focus, and a successful one. Bishop Jefferts Schori is modeling for the Episcopal Church her sense of accountability to all she serves.

I would also suggest this can be a challenge to other Primates of the Communion. I assume all are willing to be accountable, but this is a call specifically to be accountable to all orders of clergy and laity in the province. This has been an important issue, visible in the Draft Anglican Covenant and in responses to it. The proposed focus on the Primates Meeting, and corollary proposed restriction of the Anglican Consultative Council, seem to indicate a pull away from including all orders of ministry in discernment and decision making for the whole Communion. The response from the Executive Council, reflecting the majority of reflections from the Episcopal Church, highlights this as a specific concern.

I think we should honor the courage and openness of our Presiding Bishop. She is open to review and feedback from all orders of ministry within the Episcopal Church. Let’s hope that others will be willing to follow her lead.

Sunday, October 28, 2007

Finding Some Clarity

I have sometimes been told I have an obscure sense of humor (commonly, by my best beloved). Perhaps it had something to do with coming up with a series of book titles from relatives of Martin Heidegger – the one from Richard the gardener, titled Bean and Thyme; or the one from Edward, the commercial photographer, called Sign and Sight. Perhaps it had something to do with referring to our rescued shelter dog as a “Melange” (a practice I stopped after the third person said with all sincerity, “A “Melange?” I’m not familiar with that breed. Where is it from?”).

It has also been said when someone noted that I am a fact-junkie. I like browsing reference sources, just to pick up something new. When I pick up USA Today I find myself looking at the state by state snippets, starting with the state where I live, and then states where I have lived, and then states adjacent to states where I have lived….

So, I was playing recently in the Digital Archives of the Episcopal Church, looking at legislation of past General Conventions. (Take some time to browse there yourself. It’s a wealth of information on the statements and actions of General Conventions since 1976.) There I ran across Resolution 1997-A014:

Resolved, That Canon IV.15 is hereby amended by adding thereto a definition reading as follows: "Doctrine": As used in this Title, the term "Doctrine" shall mean the basic and essential teachings of the church. The Doctrine of the Church is to be found in the Canon of Holy Scripture as understood in the Apostles' and Nicene Creeds and in the sacramental rites, the Ordinal and Catechism of the Book of Common Prayer.

First, that led me to consider this definition: "the basic and essential teachings of the church… [are] to be found in the Canon of Holy Scripture as understood in the Apostles' and Nicene Creeds and in the sacramental rites, the Ordinal and Catechism of the Book of Common Prayer.” (emphasis mine) Whatever some may say about the importance of Scripture in the Anglican tradition, the General Convention in 1997 affirmed in at least one place in Canons the importance of the Church’s interpretation of Scripture rather than a sola scriptura tradition. That is even more clear when we consider that this definition was accepted as amended. The original version of the resolution was,

Resolved, the House of Deputies concurring, That Canon IV.15. is hereby amended by adding thereto a definition reading as follows: "Doctrine": The Doctrine of the Church shall be found in the Apostles' Creed, the Nicene Creed, and the Sacraments, Pastoral Offices, and Ordinal in the Book of Common Prayer, and is in all cases to be supported by Holy Scripture.

The difference is subtle, but the amended version essentially reverses, I think, the original. Rather than Tradition being understood through Scripture, Scripture was to be understood through the Tradition.

Then, it led me to Title IV Canon 15, the title of which is “Of Terminology Used in This Title” It is, in fact, a list of definitions of terms used in Title IV, which encompasses the Disciplinary Canons. In addition, it includes definitions of such terms as “Amenable for Presentment for an Offense” (“a reasonable suspicion exists that the individual has been or may be accused of the commission of an Offense”); . “Discipline” (“found in the Constitution, the Canons, and the Rubrics and the Ordinal of the Book of Common Prayer”); and “Minor: (“a person under the age of twenty-one years of age;”).

It also includes a definition of “Conduct Unbecoming a Member of the Clergy:”

“any disorder or neglect that prejudices the reputation, good order and discipline of the Church, or any conduct of a nature to bring material discredit upon the Church or the Holy Orders conferred by the Church.”

and a definition of “Offense:” “any conduct or acts proscribed in Canon IV.1.1. “

One of the complaints about the Episcopal Church has been lack of clarity and of definition. Here are some clear definitions, affirmed through the constitutional processes of the Episcopal Church. I wonder what use we might make of them.

Wednesday, October 24, 2007

In the Worst Case: Pandemic Ethics

What if the flu comes – not the ordinary, every-winter, best-guess-for-the-vaccine flu, but the pandemic? Most of us are aware in one way or another that folks have been thinking about that. A few years ago the fear was a biological terror attack; and then there was SARS; and then bird flu. Folks remember the Spanish influenza of 1918, and then think about how connected we are – remember that Patient Zero for AIDS was a flight attendant? – and are all too aware that it could happen again.

So, what if pandemic flu comes? Suppose you have 100 mechanical ventilators available. Now, suppose you have 105 eligible patients. How do you decide who gets on a ventilator, recognizing that those who go one the vent might never get off; while those that don’t will almost certainly die?

That is the archetypical scenario of discussions of pandemic ethics. They are discussions of limited resources, limited time, and establishing difficult priorities. They are discussions of rationing, and rationing when people are at their most anxious and least rational.

Monday the Department of Health and Human Services released a draft document describing priorities for vaccinations in the event of pandemic flu, that is, once a vaccine has been isolated and manufactured. You can read a news report here, and the HHS document here. I encourage you to read both.

There are some points in the HHS draft that aren’t a surprise. The first to receive the hypothetical vaccine would be critical health care workers, public safety workers, and others critical to keep the essential services going – health, fire, police, power, communications, and, of course, military and Homeland Security. Note that this doesn’t include all workers in those sectors, but only those identified as critical. Among the general population pregnant women and infants and toddlers are in the first rank.

There are two ranks after that for most employment categories. Among the general population there are, in fact, four: children are in the second rank, high risk elderly and adults are in the third, and all healthy non-senior adults are in the fourth.

There’s not much in this surprises me in the document; but, then, I’ve been aware of the conversations in my metropolitan area for some time. There may, however, be surprises to you. That’s why it’s important that HHS has opened this document for public comment beginning this Saturday, October 26. You can link from the HHS page above to offer your own comments.

When we as professionals talk about these decisions, we come back to one critical question: how do we inform the public and get some commitment from them to support these decisions, decisions that might well restrict access in the emergency for some, perhaps for many? We all project enough fear and anger and chaos if the pandemic comes – or, for that matter, any other major disaster: we remember all too well what happened to health care systems in New Orleans. We hope that an informed, reflective public will reduce that somewhat. It won’t eliminate it, but perhaps it will help.

Release of this draft is a prime opportunity to do just that: to inform the public and to discuss among ourselves how we want these decisions made, and how we think we should behave in such dire circumstances. Read the news story. Read the document. Then, take the time to offer some comment. Those of us in health care think about when, not if, the pandemic will come. Please think with us about how our society should respond, and how we should go about making the hardest decisions.

Monday, October 22, 2007

More of Rowan's (New?) Anglican Ecclesiology?

While he was making this defence, Festus exclaimed, ‘You are out of your mind, Paul! Too much learning is driving you insane! (Acts 26:24)

There are many today who want to make that response to the Archbishop of Canterbury Rowan Williams. A letter from him to John Howe, Bishop of Central Florida, is causing consternation and confusion. You can read the letter here. You can read commentary on the letter at all the usual suspects, and across the Anglican blogosphere.

The letter from Archbishop Williams came in response to a letter from Bishop Howe describing the concerns of a number of parishes that are considering leaving that diocese so as to definitively separate themselves from the Episcopal Church. As one might expect, Archbishop Williams expressed his hope that congregations might not need to separate from Bishop Howe and Central Florida, noted as being “Windsor compliant” and on the more conservative side in American disagreements. In the process of making his case, Archbishop Williams wrote this:

However, without forestalling what the Primates might say, I would repeat what I've said several times before - that any Diocese compliant with Windsor remains clearly in communion with Canterbury and the mainstream of the Communion, whatever may be the longer-term result for others in The Episcopal Church. The organ of union with the wider Church is the Bishop and the Diocese rather than the Provincial structure as such.

That might have been well enough had he left it there. However, he went on to say,

Those who are rushing into separatist solutions are, I think, weakening that basic conviction of Catholic theology and in a sense treating the provincial structure of The Episcopal Church as if it were the most important thing - which is why I continue to hope and pray for the strengthening of the bonds of mutual support among those Episcopal Church Bishops who want to be clearly loyal to Windsor. Action that fragments their Dioceses will not help the consolidation of that all-important critical mass of ordinary faithful Anglicans in The Episcopal Church for whose nurture I am so much concerned.

He went on to say,

I should feel a great deal happier, I must say, if those who are most eloquent for a traditionalist view in the United States showed a fuller understanding of the need to regard the Bishop and the Diocese as the primary locus of ecclesial identity rather than the abstract reality of the 'national church'. I think that if more thought in these terms there might be more understanding of why priests in a diocese such as yours ought to maintain their loyalty to their sacramental communion with you as Bishop.

Those statements make sense in “understanding of why priests in a diocese such as yours ought to maintain their loyalty to their sacramental communion with you as Bishop;” but they surely make difficulties regarding “[t]hose who are rushing into separatist solutions.... Breaking this [vision of the Church] up in favour of taking refuge in foreign jurisdictions complicates and embitters the future for this vision.” For, after all, does this not literally suggest that dissenting bishops can do with their dioceses what dissenting clergy and their parishes cannot?

I have noted before parallels between Rowan Williams’ vision of an Anglican Communion more closely integrated, and statements from the Pope Benedict XVI when, before his election, he issued Dominus Iesus. This letter to Bishop Howe would seem right in line with that vision: more of a centralized “church” and less a “communion of provinces,” with individual dioceses in some sense relating to the office of Canterbury directly. It certainly seems to discount provincial structures, and accountability of dioceses to their respective provincial structures.

On the other hand, in the press conference at the recent House of Bishops meeting in New Orleans, he had the following questions and responses,

Mary Ailes: one thing we have heard often is that we are free to go but we have to leave the buildings behind. Some hear that as: We have no need of you but we need your buildings. What would you say to those who want to be Anglican but cannot in good conscience remain Episcopalian?

ABC: Start by looking for arrangements and situations within what is there because grace is given through even hopeless places. Isn’t God’s grace still given sacramentally in the Episcopal Church? I would be slow to look for solutions elsewhere.

It is distressing to see the levels of litigation. I would hope and pray that there is a possibility of stopping this from being dragged through the courts interminably.

ENS: There have been interventions throughout the Episcopal Church Does this trouble you?

ABC: yes, there is a long history of unease about this in the Church. I would really, really prefer and hope to work for a local solution. My predecessor would not recognize illicit bishops I find myself in the same difficulty. More interventions make it difficult to find viable solutions.

How are dioceses to seek “a local solution,” one that doesn’t “take refuge in foreign jurisdictions,” without respect for provincial structures? Without provincial structures, what could “local” possibly mean with respect to a diocese?

Indeed, he has responded in this letter “without [intending to forestall] what the primates might say.” He is certainly consulting primates, an act that has raised for many a more curial vision that Archbishop Williams has repeatedly denied. According to one report, the primates were asked to report "your view as to how far your province is able to access the Joint Standing Committee Report assessment that the House of Bishops have responded positively to the requests of Windsor and of the Dar-es-Salaam message of the Primates." That is perhaps less “curial” in intent than some might fear, although some primates may well project their own vision of the Joint Standing Committee’s Report without further consultation within their provinces. At the same time, without provincial structures, what is the ministry of, or even the need for a primate? Moreover, what primate in any province of the Communion would be happy with such a discounting of provincial structures? What diocese in some province other than the Episcopal Church might see in this license to seek a direct relationship with Canterbury that bypasses provincial structures?

It seems as likely as not that what has happened here is that Archbishop Williams has responded to a specific question about a specific concern, and has made his best argument for those in that specific concern to seek the most “local” solution, especially when that keeps very conservative clergy and congregations in communion with a conservative bishop and diocese. Like Paul perhaps, he responded so specifically as to miss how this would reflect in the larger Communion. It is certainly consistent with his earlier statements (and for that matter elements of the Windsor Report) that emphasize resolution of these issues within existing provincial structures. (After all, once again, what meaning is there to Designated Episcopal Pastoral Oversight, or, for that matter, similar Canadian and English provisions, except within the respective provincial structures?) So, perhaps it is his continued emphasis on seeking the most local solution: for parishes, the diocese; for dioceses, the province.

Still, how shall we respond to this? Well, not reflexively, certainly. I stand by what I have written elsewhere that sometimes truth, like onions, takes low, slow, steady heat to become clear and sweet. At the same time, it also takes close attention: onions can burn and truth can become extreme without constant, careful work. Perhaps we need to work harder toward an agreement – call it a concordat perhaps instead of a covenant – that recognizes that dioceses represent the unity of the Communion but function meaningfully within the context of provinces. Perhaps we need to see responses from Anglican bishops within and beyond the Episcopal Church to this vision. We need to see with just how much glee dissenting bishops actually receive this comment, and how Archbishop Williams might respond to that. It is perhaps serendipity (or grace) that this arises just before the Feast of James of Jerusalem, whom we turn to so often these days for his gift of maintaining unity by separating essentials from distractions within the faith. What voice(s) will rise to help us understand more clearly how we might continue to live and work together within what some see as irreconcilable divisions?

But we certainly need to be watching. Untended, onions and truth will not clarify but will rather darken. This is no time to turn away from the stove.

Updated 10/23:

There has now been a response from Lambeth Palace to clarify. You can read it here. It helps; although perhaps it doesn't help enough. We'll see....

Saturday, October 20, 2007

A Christian General

Browsing again through Anglican news, I ran across an interesting story. General Sir Richard Dannatt, Chief of the General Staff of the British Army has said that part of the responsibility of a good military officer is to prepare those who serve for the possibility that they might die, and in light of that possibility, to prepare them for what comes after. Ruth Gledhill, coauthor of the news story in the Times (and a well known commentator on things Anglican), reported on her blog,

This is what Sir Richard officially said, in full: 'In my business, asking people to risk their lives is part of the job, but doing so without giving them the chance to understand that there is a life after death is something of a betrayal, and I think there is very much an obligation on ...a Christian leader to include a spiritual dimension into his people's preparations for operations, and the general conduct of their lives. Qualities and core values are fine as a universally acceptable moral baseline for leadership, but the unique life, death, resurrection and promises of Christ provide that spiritual opportunity that I believe takes the privilege of leadership to another level.'

In no small part I agree with the General. One of the reports we’ve heard again and again in light of the extensive use of military Reservists in Iraq is that they didn’t really expect they’d ever face combat. They hadn’t really considered that dying in combat was one possible consequence of enlisting, made more likely by recent changes in the military to shift many important combat support responsibilities to the Reserves. Perhaps there’s no way to really prepare them. I can only imagine that officers did their best to call Reservists to take this seriously.

On the other hand, Sir Richard seems to have a rather specific, and specifically Christian, understanding about which troops should be informed. I don’t question the stability of his own beliefs in this instance. I question how respectful it is of the troops under his command who may not share his understanding of Life, the Universe, and Everything. I can well imagine how such a statement would be received if it had come from in that form from an American military officer.

Well, we’ll just have to wait and see.

Wednesday, October 17, 2007

Universal Health Care: What Are We Waiting For?

As is my custom, I was checking out news items on the Web addressing health care, when I ran across an interesting report. It is about a study of wait times (time from diagnosis and referral by a primary care physician to performance of the procedure by a specialist) in the Canadian health system for five procedures: cataract surgery, cancer treatment, joint replacement, heart care and diagnostic imaging. You can also read about it here.

Regular readers will know that I am an advocate of a system to provide universal access to health care. Many folks, both advocates and critics of changing the American health care "system" (sometimes it's hard to apply the word "system" to something so disorganized), look at the Canadian system for comparison. And when we do, these wait times certainly constitute a major issue. It is the most common issue, I think, raised by American critics.

Now, there are some valid questions to be raised about the method and meaning of the study. First, it's very important, I think, that these are wait times for elective procedures, and not emergency or urgent procedures. These were patients that doctors thought could safely wait. Presumably, emergency and urgent cases were served in an emergency time frame.

Critics have also noted the percentage of doctors contacted who responded to the survey (less than 30%) with no reported analysis of possible differences between those who did and didn’t choose to respond. The question raised by some, for example, is whether those who were dissatisfied with long wait times were more likely to respond than those who were satisfied.

Another question I have is about the choice of these five specialty areas. They do, perhaps, offer a broad view of health care delivery. At the same time, they seem so disparate, especially in the liklihood that a procedure might be life-threatening, as to muddy comparison; or at least to confuse interpretation. After all, waiting for a cataract surgery vs a cardiology procedure would seem so different in risk as to skew comparison of patients' (or public) perspectives.

And for American critics, let's not pretend there aren't wait times in American health care. There are certainly wait times for elective procedures, if not so long. More critical in the US, unlike those measured in this report in Canada, are wait times to see a physician in the first place even to determine whether a symptom or condition is urgent. Those wait times and access issues are a major factor in inappropriate use of emergency services, and in patients neglecting preventive care, both of which raise health care costs overall.

And yet, wait times are a matter for concern, both for Canadians seeking procedures, and for Americans looking for ways to provide health care to more of our citizens. Which is why I noted in the news report the suggestion of Nadeem Esmail, one of the study authors.

To solve the problem, Canada should look at the seven European countries that spend the same or less on health care as this country for universally accessible systems but have no wait lists to speak of, Mr. Esmail said. What they have, and Canada does not, is user fees that prevent needless use of health care, competition between public and private operators for public health funds and a separate private system that can siphon off some demand, he said.

I think there are two points to note here. First and foremost, in looking for ideas for improvement Mr. Esmail does not look to his neighbors to the South. He does not look at our “market-oriented” system.

Rather, and second, he looks to European models that manage to provide universal access without the more significant wait time and waiting lists. The brief description he offers highlights an important role for government in providing universal health care. It is not “socialized medicine,” with government ownership of health care institutions and employment of providers – the straw man of health care conservatives. Instead, the systems he points to have universal participation (some responsibility for those receiving care) and what we speak of here as public/private partnerships. They have systems in which interaction between the government and private interests, that might include competition or cooperation, can still provide universal access.

This is an interesting study regarding wait times in the Canadian health system, and I’m sure we’ll here about it again – probably from health care conservatives trumpeting the flaws of the Canadian system. But if we read in more detail, there is much with which advocates for universal care can challenge them: other models somewhere between the poles of true socialized medicine and “market-oriented” inequity. If we can acknowledge that universal coverage is not only morally desirable but also economically possible, and can look for new models to provide it, perhaps we can make progress toward providing care for all our citizens.

Monday, October 15, 2007

Serving Body and Mind and Spirit

Peggy Treadwell, a colleague at Episcopal CafĂ©, recently wrote of her experience in recognizing and adjusting to her mother’s aging and increasing frailty. It is a moving piece, and I commend it to your attention.

Part of what caught my attention was her first sentence: “My mother regularly tells me she is ready to die.” That sentiment used to get me regular referrals from the Consultation/Liaison Psychiatry Department in a hospital I used to serve.

The referrals would come to me from one of the staff clinicians – one of the psychiatrists or the clinical psychologist. The referral was always for the same concern: a medical resident would refer to the Psych staff a patient who the resident thought might have suicidal ideations – thoughts about committing suicide. Now, that’s not an unknown referral for a chaplain, but it’s not that common, and it’s not common at all for the referral to come from Psych staff.

So, I would go to see the patient; and inevitably the circumstances were largely the same. I met an elderly, faithful evangelical Christian. The patient would be happy to speak with me, and especially happy to speak about his or her faith. And, as I knew it would, somewhere in the conversation about the patient’s illness and condition, the patient would say something like, “I know the Lord, and I’m not afraid to die. I know Jesus, and I know I’ll be with him, and if he’s ready to call me home, I’m ready to go.”

Now, perhaps to most of my readers that might seem banal, and certainly not suicidal. But in fact the referrals came to me this way: first, a resident, commonly a foreign national and graduate of a foreign medical school, and commonly not a Christian, would meet the patient to take a history and physical. In the course of discussing the patient’s understanding of his or her disease, the patient would make the statement above. The resident, entirely unfamiliar with a sentiment so common among elderly and ill evangelical Christians in the United States, would perhaps probe a bit further. The patient, of course, would affirm the statement that he or she was not afraid and was ready. To the resident, this seemed not only potentially suicidal but also persistent and determined. So, the resident would chart his or her concern, and make the referral.

The Psych staff would then discuss this with the resident. It helped a great deal in their assessment that the three staff clinicians, and most of the clinical psychiatric nurses who worked with them, were raised and educated in North American culture. It was even more helpful that they were most of them faithful believers. One psychiatrist was an active Roman Catholic, while the other was an observant Jew; while the psychologist was an active Presbyterian. The psych nurses represented a variety of traditions. And so they understood quite well what the medical resident was describing; and they understood it was quite unlikely to be true suicidal ideation.

And so the referral would come to me. I would then see the patient and have the conversation I described above. I could then make my own record in the chart, noting the resident’s note and concern, and expressing my own assessment. At the time to make it sound a bit more clinical I would write that such language was “within normal limits” for the thinking of elderly evangelical Christians.

And often that was not the end of the story. Another chaplain and I frequently attended the Consultation/Liaison Psych weekly Case Conference. There we had the opportunities to give our own perspectives on these and other cases, and to participate in the education of psych and medical residents. (They were also quite indulgent: they put up with the project I had then of identifying a country song for every major psychiatric diagnosis.) It was a valuable, and an unusual opportunity to bring the importance of a faith perspective in a clinical psychiatric setting.

I know how unique that experience must seem; and I’ll admit I haven’t had one quite like it since I left that hospital. At the same time, my experience has been that in fact psychiatry and psychology professionals have been respectful of how important faith can be for a patient, and respectful of those of us who respond professionally to that faith. In part it’s from simple sensitivity to and respect for the patient, regardless of the professional’s own opinions in matters spiritual. But it’s also been my experience that those professionals, whether psychiatrists or psychologists, and particularly clinical social workers, do indeed respect professional chaplains as “advanced practice” and specialized ministers. That’s not to say that there aren’t still out there those classical and neoclassical analytical types – successors to Freud and Adler and their disciples, more likely to see pathology, sort of like Communists, under ever bed. And there are certainly those who feel unprepared to address these issues in the patient’s own terms, however spiritual they may feel in their own lives. But most I’ve found, as I’ve said, to be respectful of the patients in their faith, and respectful of those of us who address issues of faith in the clinical environment, sharing in the same commitment to approaching the care of patients with respect for their integrity and personhood. Indeed, by and large they have professional respect for most clergy, and for the patients’ relationships with their clergy.

That’s not to say that they respect all clergy; but in fact the problems they have with clergy and clergy-parishioner relationships are also shared by chaplains. Clergy who deal solely in fear, or who manipulate their patients to maintain control, are concerns for behavioral health professionals and chaplains alike. I have said that my response to the old joke about the cleric who commented that God was in charge and he was only in sales, is to say that I am in maintenance. I have found many opportunities over the years to work to repair damaged relationships with God and with other people that were structured and damaged specifically and particularly by clergy.

There are also those clergy (and this sometimes includes chaplains) who think they understand behavioral health issues and diagnoses much better than they actually do. I’m not a psychologist, even though I’ve had more exposure to and training in behavioral health care than many clergy. And there are those clergy, including colleagues in chaplaincy, who have sought out academic and clinical education in psychology and counseling. On the other hand, we have all, I think, encountered clergy who have thrown around psychological terms in ways that simply demonstrated that they didn’t know what they were talking about. The results were often parishioners who ended up labeled rather than helped.

But in fact most of us know our limitations. Folks in behavioral health know their limitations in addressing issues of faith, and we in ministry know our limitations in addressing psychiatric issues. And in that knowledge we have found ways to work together to benefit those we serve. My situation in that previous hospital was unusual in its structure; but I have found the intent to serve together and the respect to make that possible is quite common. It is a recognition that human beings are creatures with bodies and minds and spirits; and that to care for the whole person is to care for body and mind, and for the spirit as well.

My Latest at Episcopal Cafe

A couple of other places to find my recent comments:

First, my newest post is up at Episcopal Cafe. If you're not yet familiar with Episcopal Cafe, start with my post, and then read some of the other essays. I'm honored to be in such good company. I think you'll appreciate the quality of information and essays at the Cafe.

Second, I had a rant a few days ago on matters liturgical. It was in response to a news item at the Cafe. You can find my comment here. Read the original post, and the other comments; and then leave your thoughts as well.

Tuesday, October 02, 2007

The Overlooked Question: Who is a Person?

Over two recent Sundays I led the Adult Forum in a local parish. As I've done before, I began with the "Georgetown Mantra," and then worked with them to explore what other, perhaps more Christian, more Episcopal values we might want to bring to the discussion.

One of the issues brought home to me again is the question of what we mean when we use the word "person." Where, somewhere between the encounter of egg and sperm and independent breathing and squalling, do we say, "This now is a person?" At what point, somewhere between "this now is a person" and some legally-defined age, do we say, "This person is now an independent person with full legal rights, responsibilities, and protections?" At the other end of life, how much function, both physical and cognitive, must a person lose to lose the dignity and integrity and protections of being a person. And in between are there events, including individual choices and actions, that can result in loss of personhood?

In health care, of course, this has impact in many areas, even if we don't necessarily speak explicitly of "personhood." After all, the principle underlying the entire "Georgetown Mantra" is "Respect for persons." We're certainly conscious of it in the issue of abortion. At the same time, it is important in other areas. For example, discussions of when to allow natural death (if one can consider it "natural" after we've started treatment in the first place) have to do with personhood. Many folks who complete health care treatment directives set as one of their standards of "a quality of life acceptable to me" the capacity to make decisions, and/or to communicate. Without those capacities, have they lost "personhood" in a meaningful sense? What about severe brain injury, or brain disease, or brain death? Certainly, those raise issues of personhood, legally as well as morally; and we know this best when we say to families trying to make hard decisions in the midst of grief, "The person you know and love will not come back, no matter what we do from this point."

We even are looking at issues of personhood in matters of informed consent. When a person's capacity to consent is limited (legally by age, or functionally by limited cognitive capacity), we still assess whether the person can give assent. So, we will discuss issues of consent with a 16-year-old that we would not discuss with an 8-year-old; even though both have the same (lack of) capacity to consent.

The troubles that tear at churches these days are also about personhood. We're more conscious of it in liturgical churches, when we look at specific rites and who might be persons appropriate to participate; but all churches wrestle with it at some point. (So, I'm sure, do non-Christians; but I can't speak to that.) Again, are there events or actions that cause the rest of us to feel someone has lost or rejected moral or legal personhood? Some folks are arguing bitterly whether sexual acts have that result; and if so, which acts. Certainly, all parties begin acknowledging personhood; but sooner or later someone gets around to, "yes, those folks are persons, but...." At that point, we're not simply discussing social norms; we're discussing qualifying personhood.

In all of our moral reflections, we need to keep this concern in mind. It's all too easy to pursue principle over persons, or at least over the certain persons in the specific events. We want to discuss moral principles and ethical processes as if we all agreed on "personhood." But next time you're in that place, wrestling with moral conundra and difficult decisions, it will be worth it to step back and think again: who are the persons involved in this? And, just how do I understand and value personhood - theirs, and our own?

Problems Basing Human Studies on Animal Studies

A few days ago I was listening to BBC World Service on my computer, when I caught just the end of a news report. What caught my attention was a statement from a British medical researcher that went something like this: “We base our medical studies on humans on our studies on animals. But, if the studies on animals don’t follow the same standards, don’t have the same quality, then how can we trust the results? Is this what we’re basing our human subject research on?”

Well, I went digging, but I couldn’t find the news report. (If someone out there can, I’ll be happy to give a more accurate quote and appropriate credit.) However, I did find this. This is a study by Luciano E Mignini, MD and Khalid S Khan, M.Sc. and a Member of the Royal College of Obstetrics and Gyenecology, titled, “Methodological quality of systematic reviews of animal studies: a survey of reviews of basic research.” The article was published at BMC Medical Research Methodology, an online journal.

You can get a sense of the concern the researchers were addressing from their “Backgrounds” section:

In the development of new health technologies, it is widely held that drugs or procedures should first be assessed in animal models before proceeding to clinical trials in humans. High quality systematic reviews provide unbiased overviews of the available evidence. There have been calls for application of this approach in basic research, particularly in animal research, to better understand biological plausibility and to translate findings of basic research to the bedside. Cumulative assessment of emerging evidence in animal research can help rationalize human clinical trials. The idea that these experiments impact future human studies is well recognised, but lack of systematic review of this evidence can lead to a sort of research bias that has seldom been previously considered explicitly. The link (or lack of appreciation of a link) between animal and human studies is illustrated by the case of nimodipine in focal cerebral ischemia; it has become clear from systematic review of animal experiments that there was no convincing evidence to substantiate the decision to perform trials with nimodipine in humans Because the initial animal studies were not evaluated systematically; human trials of nimodipine proceeded at significant cost and potential human risk despite a lack of clear scientific rationale. The extent and the quality of systematic reviews of animal studies is unknown. The aim of this study was to assess the methodological features of such systematic reviews.

To translate: when preparing to do medical research involving human subjects, scientists review the literature for reports of relevant research on animal subjects. Part of what they look for is reviews of research on animal subjects. However, research studies on animals haven’t been subject to the same qualitative review that is common in studies on human subjects; and, as a result, decisions can be made based on animal studies that aren’t in fact well done. Therefore, they decided to review a large group of animal studies for standards of good research practice that they felt would be necessary for good human subject research. In describing their own methodology, they list the standards and procedures they’re looking for.

The results of their review?

From 4749 citations initially identified, 1517 were considered potentially relevant and their full manuscripts were evaluated. Among these, there were only 30 (1.9% of 1517) reviews of animal studies that met our selection criteria. The reviews summarised studies of animals including cat, cow, horse, dog, mouse, nonhuman primate, rabbit, rat, sheep and swine amongst others. The ranges of topics included cardiology, dentistry, gynaecology, immunology, neonatology, obstetrics, oncology, toxicology and urology amongst others….

There next paragraph goes on to detail the standards by which significant portions of those 1517 studies fell short.

Now, this is an important issue in medical ethics. As the authors note, studies involving human subjects are determined to worth pursuing, both in terms of results and in terms of benefits outweighing risks, based largely on studies in animals. However, the assumption is that those animal studies are well done, and meet sufficient standards for quality. If those studies do not meet sufficient standards, they mislead researchers, wasting money and time with no benefit to patients. The authors citation of the nimodipine studies is a case in point.

Moreover, not only are such poor studies not sufficient grounds for moving forward to human studies, they are not adequate justification for any risks and suffering for the animals. After all, it is a recognized principle in human subject research that a study that will not produce usable results by definition places those human subjects at inappropriate risk. If these animal studies are not producing usable results, they put the animals at a risk that is at least wasteful, and is demonstrably immoral.

I am also concerned about this study because it brings me back to a favorite soapbox: the tendency for any research study that shows progress in a disease that we fear to show up in the evening news. There is always the caveat that “it will be years before we know whether this will result in a new treatment;” but by that point the damage is done. The public has been told of a study result, and told that the result was hopeful. If the study is good, that may well be in question: it is a long way from an animal study to a useful treatment for humans. If, on the other hand, the study is poor it is indeed false hope, perpetrated by haste. Particularly where there are people suffering with diseases for which we currently have little to offer, bad studies are mercy delayed and distracted; and indiscriminate publication in the broadcast media is little better.

I’m sure others will be looking at this article with their own reviews and arguments. I think that will be good, and will move medical research forward. However, in the meantime we need to take animal studies with a grain of salt, both those in research and we in the larger community. We trust – we can only trust - that researchers will carefully evaluate animal studies when they seek justification to move forward with human subjects. We need whenever we can to express our own concerns that those studies be done according to the highest research standards.