Wednesday, March 26, 2008

The Chaplain Gets Schooled

I have been blessed in the last couple of days with emails from The Revd Canon Dr Michael Poon, Convener of the Global South Anglican (GSA) Theological Formation and Education Task Force. He took the time to read my recent reflections (here, here, and especially for this post, here) on the Anglican Catechism in Outline (ACIO), as well as my related post at Episcopal Cafe, and to write to me. I’m honored.

He also had some comments, and especially one that caught me. In the Episcopal Cafe post, I wrote, “the paper on the Holy Scriptures by Professor Oliver O'Donovan of the University of Edinburgh takes a position on Scripture that is explicitly inerrantist and implicitly literalist” (a more concise statement of what I wrote here). His comment was, “Sorry, I cannot understand this assessment.”

So, my first thought was to be sure I hadn’t confused my terms. Having been raised where I was surrounded by folks who spoke of Scripture as “verbally inspired, literally true, inerrant and infallible,” and used that phrase as if it were one word, I had to consider the thought that I might have confused my terms.

And I think perhaps I have. Although I need to do some more rereading, I’m thinking more that Professor O’Donovan is committed to biblical infallibility rather than biblical inerrancy. (Yes, I know the limitations of wiki anything, but these articles seem a good place to start.) Mind, I’m still working with this, but that’s what I’m thinking this afternoon. Dr. Poon did recommend this sermon of Professor O’Donovan’s for more exposition, and certainly the Commentary attached to ACIO reflects much of the language of the sermon.

One of the difficulties of our current Anglican discussions has been differences on what “the real issue” really is. Some think it’s human sexuality. Some think it’s differences on the authority of Scripture, of which differences on human sexuality are only symptoms. With that in mind let me recommend reading, “The Chicago Statement on Biblical Inerrancy with Exposition.” It’s an interesting document, and not a long read. At least one signatory, J. I. Packer, is a voice in our current discussions. It’s not hard read, but it’s more subtle than some of us might expect. If it helps us clarify our terms and our understanding of one another, it’s well worth noting, whether or not we then agree.

So, I appreciate feedback that makes me think, and I’m still thinking on this one. I’m certainly grateful to Dr. Poon for that. I also want to note that he and the Theological Formation and Education Task Force have invited feedback. According to the announcement of Interim Report, they would like to have feedback by April 30:

The Revd Canon Dr Michael Poon
Convener, GSA Theological Formation and Education Task Force
c/o Diocese of Singapore
St Andrew’s Village
1 Francis Thomas Drive #01-01
Singapore 359340
Fax: (65) 6288-5538; Email:

Dr. Poon has been gracious about my comments, and I hope others will offer theirs. In the meantime, I’m off to think harder....

Monday, March 24, 2008

Transplantation and Transparency

Recent news reports have raised questions about the number of persons in the United States waiting for organ donations. You can read the Washington Post story here and a commentary by ethicist Arthur Caplan here.

It has been a truism for years that the number of those who might benefit from organ donation has been roughly four times the number of organs donated. In one sense, it doesn’t seem to make a lot of difference whether that multiplier is closer to three times than to four times organs donated. At the same time, critics are correct that it certainly can make a difference. Caplan cites a number of examples.

There are several issues regarding distribution of organs that don’t lend themselves to simple resolution. For example, should distribution of organs be on a national or regional basis? Some large centers, with larger numbers of patients on their own lists (or better, perhaps, their portions of “the list”), would like national distribution of organs to the first appropriate donor, rather than assessing first those patients geographically closest to the donor patient. However, increased transportation time does have an effect on the viability of the organ, and conceivably on the viability of the waiting patient. Those extra hours can make a significant difference. And certainly patients who might benefit from transplant are spread all across the country. On the other hand, the larger transplant centers argue, and not without reason, that in doing more procedures they have more experience and so greater likelihood of having good outcomes. Some patients and families literally move so as to be closer to those centers. Currently, the norm is regional distribution first, but the discussion recurs periodically.

Another issue is “presumed consent” vs. “presumed denial.” There are patients who die, sadly, with no family or community at all, and sometimes completely without identification. Many patients who die suddenly have expressed no opinion on donating their organs. In those cases, should the presumption be that they would wish to be generous and donate their organs; or should it be that they would decline to donate? Donation is certainly generous, and Americans are certainly generous people, at last over all. At the same time, to what extent should that guide our presumption in the individual case? At this time the practice is to presume denial, to presume that if the individual did wish to donate the individual would have made that known, whether by joining a donor registry or informing family, or at least signing the appropriate line on a driver’s license. However, in much of continental Europe the norm is “presumed consent,” and the position certainly has its advocates in this country.

The concerns about the number of patients awaiting transplant do point out the importance of transparency in the entire process of donation and transplantation of organs and tissues. I think that would be a matter of general agreement of everyone involved. That said, for the good of patients who might or might not benefit from transplantation, and for the good of families who might consider donating the organs of a loved one, there’s no such thing as “too much” transparency. We need to keep these issues out in public discussion. That way both as individuals and as a society we can decide according to our wishes and our values.

Thursday, March 20, 2008

Remembering Arthur C. Clarke

I, for one, have been saddened by the news of the death of Arthur C. Clarke. I enjoyed a great many of his works.

According to Clarke was an atheist. At the same time, he was, as I see things, clearly involved in spiritual reflection. Understand that for me, spiritual exploration most broadly addresses three questions:

  • What do I believe about Life, the Universe, and Everything? (And yes, I am also a fan of Douglas Adams.)
  • Who am I, what is my place, in Life, the Universe, and Everything?
  • How should I behave in light of who I am and what I believe about Life, the Universe, and Everything?

I think those three questions can be referred to as Theology, Identity, and Morality.

Clarke clearly dealt with these, and sometimes explicitly. Two of my favorites were the short stories, “The Nine Billion Names of God,” with it’s final sentence, “One by one, without any fuss, the stars were going out;” and “The Star,” with the internal conflict of the astrophysicist, himself a Jesuit, with the thought – the fear, really – “that these creatures should have to die that a star might shine over Bethlehem.” And there were others. His novel Fountains of Paradise incorporates Buddhist prophecy as a significant element. His story, "The Sentinel," from which the "2001" cycle began, pointed to life beyond our knowledge, if not exactly beyond our conceiving. Even the "2001" cycle itself raised issues. Ultimately we discover creatures far older, far more experienced, and in many ways far more poweful than ourselves. But, if we are to accept the God acts through human beings, why should we imagine God couldn't act through other sentient beings? For those of us who seek to balance belief the God is the Creator with the evidence that the process has taken a lot longer than six days, his writing was cause for reflection and humility.

Arthur Clarke has gone beyond once again, exploring beyond the limits of what we know. May he rest in peace.

Wednesday, March 19, 2008

Up at Episcopal Cafe: Thoughts on ACIO

My most recent contribution has now gone up at Episcopal Cafe. You can read it here. The point is the importance of continuing attention to our Anglican colleagues in the Global South. The presenting issue is the "Anglican Catechism in Outline" (ACIO), published as part of " The Interim Report of the Global South Anglican (GSA) Theological Formation and Education Task Force"

I have also done more detailed reflections on ACIO and on other sections of the Interim Report. If you're interested, you can read them here, here, and here.

Monday, March 17, 2008

Hospital as Garden

It’s planting time at our house. Oh, it’s still too cold outside even to work the ground. much less to plant. But inside the seed racks are set up and the lights are hung. The seed mats, providing gentle warmth, are in place. It’s planting time.

My Best Beloved loves to garden. I love to harvest. She loves to watch things grow. I love to cook and eat. There is a price to be paid to harvest, cook, and eat. Part of that price has been to set up the racks and shelves and to make the light fixtures that fit them, so that planting can begin a long time before the last hazard of frost.

My Best Beloved and two friends from church spent time Saturday planting. Seeds for tomatoes, sweet and hot peppers, eggplant, and basil went into fiber containers of custom-blended potting mix. The seeds will rest there, sheltered in an environment as ideal as could be until they have grown strong enough to face the elements, to grow and thrive out in the garden. They will start in the dark, enveloped in rich soil, warmed from underneath, until they break forth. They will discover waiting for them light, bright and strong and close, carefully timed to provide both energy and rest.

This thought started as a meditation for a hospital Leadership Meeting. I start the meetings with prayer, and try to incorporate some reflection on the world beyond the hospital into my comments. Often enough those come from my own back yard, from the garden or from my fruits and berries. Well, today’s meeting got postponed two weeks; but the meditation would not wait.

You see, it occurred to me that this is much of what we do in the hospital. Those who come to us are vulnerable, not strong enough or healthy enough to face the world. For them it is often a time of darkness, a time of burial. However, in fact it is intended to provide the optimum environment for healing and growth. In our patients we look for the potential that they can grow and thrive and bloom, if only we can provide the right medium and resources. We seek to provide that for them – the right environment, the right nourishment, the right balance of work and rest – so that they can return to the life they have known, able not only to survive but, more, to thrive. For many it is indeed an experience of breaking through from darkness into light, from potential into growth and blossom.

I know there are other relevant reflections on this topic; and at this season I frequently ask patients if they have a new perspective on resurrection. But that will wait until next week. Today and in the meantime, may God grant all of us in health care that we may take our part in providing that environment – that optimum medium and nourishment and warmth and light – that will support our patients and help them to heal and grow and thrive.

Thursday, March 13, 2008

Health Care and "the Market"

Goodness! Has it been a week?

Have I written yet about marketing in health care? Well, then, it's about time.

I worry (actually, I usually snort and grumble) when influential people, whether government officials or "talking heads," or even academics, start talking about health care and "the Market." To some extent that reflects my belief that for-profit health care is a sin. However, it also reflects my conviction that most of those folks don't understand how "the Market" really works in health care.

Between our general experience of living in a retail market economy (remember, don't save that government rebate; we need you to spend it!) and our specific experience of autonomy-oriented health care ethics, we perhaps might expect that we would be the target of health care marketing. And of course we would be wrong.

We would be wrong because the marketing efforts all too frequently aren’t oriented to us as individual patients at all. Instead of being the customers to be attracted, we are the commodity to be negotiated. Health care institutions put their best efforts into attracting insurance plans and physicians. That’s because we as patients don’t really make our decisions about where to get health care in an unconstrained market. We go where our health insurance plan tells us we can. That’s certainly true for those of us with employer-provided health plans; but it’s also true for others. Between decisions of physicians to refuse new Medicare or Medicaid patients, or restrictions because Medicare or Medicaid patients have chosen to participate in a specified HMO plan, many of those on government-funded plans are also constrained in their choices. For those who have a relationship with a physician, most will choose to seek care where that physician recommends, or at least where that physician practices. So, we don’t make those decisions without some limitations.

For the health care institution, it is the insurance plan and the physician who can deliver patients, so that’s where the institution focuses energy in marketing. The more and bigger the health plan contracted, the more physicians credentialed to practice in the institution, the more potential patients available, and the more actual patients who will come for care. With health plans, institutions negotiate on price and patient outcomes. With physicians, institutions negotiate on resources available for patient care and on resources available to the physicians. (Note that nobody actually negotiates with Medicare or Medicaid. Government officials determine what the plans will pay – usually a percentage, well below 100%, of what they think the institution’s costs ought to be, whatever they might actually be – and then say, “Take it or leave it.”) So, institutions get caught in a bind: they have to pay for newer and better equipment and systems to attract physicians, and somehow pay for them with lower reimbursements from health insurance plans. Now, patients might be benefiting in some sense, both from the latest equipment and from arguably lower insurance premiums; but institutions don’t market to patients on that basis. (And let’s face it: “arguably lower insurance premiums” begs the question of “lower than what?” They seem only to go up.)

Since most, and the best paying, insurance plans are provided by employers, insurance plans and institutions both market to businesses. Insurance plans tend to market to them on cost, and to some extent on outcomes. Institutions tend to market to them on quality of care and of patient outcomes.

Health care industries, both pharmaceutical companies and equipment manufacturers, market to physicians and to institutions. They market to both on the basis of quality of patient outcomes (at least according to the information they provide, which is largely accurate but limited only to their products), and to some extent on costs. In recent years some of the more egregious marketing techniques, especially food and travel provided to physicians and other professionals, have been questioned and significantly reduced. Industries also market to insurance plans to argue that the plans should include their products on their lists of approved drugs and procedures.

So, if we’re not the primary target for marketing in health care, why do we see so many ads? Why all those ads on television or in magazines for medications? Why all those ads on television or in newspapers for health insurance plans? The answer is clearest in those pharmaceutical ads. Somewhere the sentence will come up, “Ask your physician is this medication would be good for you.” The ads are not so much to encourage our decisions as to get us to influence the decisions of others. Physicians really hate being asked about drugs that are utterly inappropriate for the patient in front of them, and will resist giving meds that wouldn’t be necessary. On the other hand, when deciding between reasonable Medication A and reasonable Medication B, they might well follow the patient’s request. After all, they want to keep the patient’s trust. They might well consider interactions with other drugs. On the other hand, they might not be aware that one is significantly more expensive than the other, or that one is measurably more effective than the other. After all, they can’t keep up with the formularies of 400 different health insurance plans, and they have precious little time for continuing education. The drug companies know that if enough patients ask, doctors’ prescribing practices can change.

By the same token, insurance plans and healthcare institutions know that if enough employees ask, employers will consider that in deciding on what health plan to purchase. Both know that, by and large, patients will go to institutions “in plan” for care; but if enough patients tell their employer that they’d prefer to get their care in one institution instead of another; or if there is an attractive program offered by one institution instead of another; or if one institution asserts it can get sick employees back to work sooner than another; employers are going to pay attention.

Now, some institutions do “market” to patients in a sense. However, the most important means for doing that is in fact the care the institution provides. They know well that patients who feel they’ve been well cared for and treated with respect will return, and will also recommend the institution to others. Those who feel they’ve been treated poorly will not only not return, they will also tell others of their experiences – indeed, they will tell more people about a bad experience than they will about a good one. And this is about feeling that people care and that respect them much more than about outcomes. Patients and families who feel compassion even in the midst of tragedy will think well of the institution. Patients who feel neglected will dislike the institution even in the best of circumstances.

So, I continue to be wary of those who want to wax eloquent about “the Market” for healthcare, and especially those who seem to think that “the Market” operates around the decisions of the individual patient. I fear that either they don’t understand how the market actually works in health care, or they don’t want us to understand.

Wednesday, March 05, 2008

Armed Conflict in the Episcopal Church

Have you been paying attention? There is armed conflict within the jurisdictions of the Episcopal Church. What, you hadn’t noticed?

This past weekend soldiers from Colombia crossed the border with Ecuador to attack and kill a leader of the Revolutionary Armed Forces of Colombia (FARC). In reaction both Ecuador to the southwest and Venezuela to the northeast have mobilized their armed forces along the borders. President Chavez of Venezuela has made vague threats, while Colombian forces report they captured a laptop computer with information suggesting that Chavez has been bankrolling the FARC to some extent. Ecuador has in any case known for some time that the FARC bases were there.

One thing we need to consider as we listen to this from across the Caribbean is that Colombia, Ecuador, and Venezuela are part of the Episcopal Church. Specifically, there are dioceses of Province IX of the Episcopal Church. Indeed, only last month the Executive Council of the Church met in Ecuador. This is one of the consequences of the reality that the Episcopal Church is not only the Episcopal Church in the United States of America. The Anglicans in those South American nations are part of our Anglican province, and not of another.

Most news sources say that actual military conflict is unlikely. We can pray that it won’t happen – among those things the world needs no more of is another armed conflict. At the same time, we need to appreciate that those involved include not only our brothers and sisters in Christ but our brothers and sisters in the Episcopal Church. Pray for peace in the region, and for our Episcopal brothers and sisters in Colombia, Ecuador, and Venezuela. Pray, and reflect that their troubles are not so far from us after all.

Tuesday, March 04, 2008

The Chaplain on "The Chaplain"

Updated Tuesday afternoon.

I’ve been caught up in Anglican stuff this past week. However, I wanted to come back to a question I had. In responding to a post last week, I received this comment:

anonymous said...
I apologize for using the comment box for an off-topic inquiry I'd normally do through email, but I didn't see an email address for you and I'm curious to hear your response to a Hollywood depiction of chaplain interacting with a terminal patient that is being touted as "typical" of "liberal" chaplains by a certain self-proclaimed "orthodox Anglican" website.

If you find it beneath commment, I certainly understand, but I thought someone who has actually has some expertise in this area (and is not merely trying to erect a straw man to score political points) might offer some useful insight.

Link to Annoyingly Tendentious Website

Rather than send you back to the “Annoyingly Tendentious Website” (and remember, that was the poster’s comment. not mine), let me send you to this. This is the better YouTube clip, and it provides more information than that to which “anonymous” pointed. Take the time to view it and come back.

I don’t watch “ER” – haven’t in years. I enjoyed it at the beginning, but eventually it failed to hold my interest for the same reason that all medical dramas have failed with me for more nearly thirty years: they just don’t portray real life in hospitals. Fact is, life in hospitals, and especially life in emergency rooms, involve occasional excitement with a lot of daily grind in between. It’s not exactly like that comment from the pilot about “hours of boredom punctuated by moments of sheer terror,” but it’s not too far. Most of us who live in hospitals don’t want as much drama as a TV show would need. At the same time, there’s usually enough drama in our real world to go around. I’ve worked in inner city trauma centers most of my career, even if I now work in a smaller, suburban hospital. People don’t bang doors open, and they don’t come running and screaming. Indeed, these days emergency rooms are secured, and doors wouldn’t bang now matter how hard someone tried.

Most especially, hospital dramas don’t commonly have chaplains or social workers, and so physicians – all too frequently Intern and Resident physicians – and nurses get written as providing a lot of emotional support and social service. That just doesn’t happen. It’s not that they don’t care. It’s that there aren’t enough physicians and nurses around to do what physicians and nurses are trained to do, and they don’t have time to stop and do what chaplains and social workers are trained to do. Doctors and nurses don’t always understand how we do what we do, but they’re absolutely ready to give us room to do it. They generally don’t have a choice: they just have too much else to do.

So, I will say up front that I didn’t see this episode of “ER” broadcast. However, I was able to find more and discover more than the first link provided. That will become important.

When I looked at the link that my anonymous respondent suggested, I noticed how many folks commenting at that site were critical of what they described as “New Age” or “progressive” or “liberal” pastoral care. One or two even blamed CPE. Well, having looked at the selection that I recommend, I don’t like those labels, but I also don’t like the mistakes obviously made in getting to this point.

Here is the setting: Chaplain Julia Dupree sits in an ER room with a patient, one Dr. Truman. While injured himself, Dr. Truman is also concerned about another patient in ER, a young boy whose life the doctor saved. However, the Chaplain learns there is more to the story. Dr. Truman is a prison doctor, one who carried out a number of executions by lethal injection. One of the prisoners so executed was in fact the father of the child whose life the doctor saved. Worse, that execution was complicated. The patient’s IV infiltrated – it got backed up and blocked – and the patient didn’t die. Following procedure, Dr. Truman started a new IV, started new drugs, and the patient died. Dr. Truman is terribly aware of all of this, as is the child’s mother. She confronts him during the show, saying, “This doesn’t make up for it. I will never forgive you.” And so by the time he meets the chaplain, Dr. Truman has decided he can’t forgive himself, and he can’t expect God to forgive him.

Let’s be clear: right from the beginning the chaplain made a significant mistake. She fails to assess who and where her patient is, emotionally and spiritually. Right at the beginning of the scenes in the link I prefer, a rosary is quite visible in the patient’s hands. That would suggest the patient is Roman Catholic, and would raise questions about his participation in executions in the first place. Moreover, as he tells his story he makes clear that in hindsight he has interpreted the infiltration of the IV as divine intervention. “God sent me a sign, and I ignored it.”

The chaplain does not believe the patient is beyond forgiveness, and so she jumps to offer words of comfort, and to suggest, without being explicit, that God has already done what the patient only needs to accept and appreciate. But, the patient isn’t there. The chaplain appears unable to wade into the patient’s pain and guilt and be there with him. She isn’t prepared to let him guide her in meeting his needs, even to let him decide what he thinks he needs. She doesn’t consider whether this would be an appropriate referral, if he might benefit from sacramental penance. She doesn’t consider whether to confront him, to ask whether he really believes he is more powerful than God, that his sin is beyond God’s capacity to forgive. She simply asserts that he is forgivable, and even already forgiven, a thought that, true or not, the patient is not prepared to hear. His ability to trust her collapses, and he throws her out. Nor can she see this as something that at least validates and empowers the patient (after all, who else in that setting can the patient actually throw out?). We learn later in the next clip that this is for her a major defeat, one that prevents her from trying again.

It’s in that clip that we realize why she made the mistake. Talking with a supportive physician, she says, “People in crisis want rules, structure, something to lean on, I get that; but it’s not me.” But, it’s not supposed to be about her. It’s supposed to be about the patient. She speaks about her education, and her varied spiritual background and experiences. She says, “I thought an inclusive approach to spirituality would work in a place like this.” She’s right, and the physician affirms it. But in this instance she failed in being inclusive of this patient. As much as she wanted to be there with him, she failed to be there for him.

This highlights a mistake made by the writers. This young chaplain has education and training, but appears to have little foundation of her own. I’ve found it very difficult to find any backstory for this character, but in this instance she seems uncertain of her own foundation, her own tradition. This is something missed by advisors to the writers. The professional organizations that educate and certify for chaplaincy require ecclesiastical recommendations and endorsement: evidence that in fact the chaplain or student come from a specific faith tradition and is conversant with that faith tradition. To be available to someone else, the chaplain needs some clear sense of who she or he is, of where he or she comes from emotionally and spiritually. It helps me as a chaplain to encounter even those most different if I know the tools of my own faith, and my own limitations. There are no “generic” chaplains. Instead, there are chaplains from various traditions prepared to care for and support, to the best of their ability, patients and families across the spectrum of human beliefs. And a long time ago a student taught me profoundly that enthusiasm is no substitute for groundedness, something that education and training in themselves won’t necessarily provide, and certainly won’t replace. In that room this chaplain couldn’t be there for this patient because she couldn’t be there for him instead of for herself. My fear is she couldn’t be there because she wasn’t sure where she was in the first place.

But let me note this: unlike most of the commenters at conservative blogs, I don’t think the problem was the basic technique. This chaplain did not fail because she took a nondirective approach, or because she held a progressive faith. This chaplain failed because she was not prepared to accept this patient where and as he was – something that throughout my career I’ve seen from clergy across the Christian spectrum, conservative and progressive, “left” and “right,” High and Low and Broad. Some of the commenters, so delighted to find fault with her, make exactly the same mistake.

This is just a short reflection. I’d love to see a transcript, to take this to a group of CPE students and see what they do with it. Perhaps folks commenting here can add, as Malcolm+ did in responding to anonymous’ initial comment. The presence of a chaplain is not likely to bring me back as a viewer of “ER.” On the other hand, any presence of a chaplain (or any other clergy, for that matter) in the media who’s trying to help and not to manipulate or control is worth our attention, and perhaps an opportunity to reflect and to learn.


If you're interested, there are two other web pages reflecting on this character on "ER," one of which refers to this episode. At PlainViews Chaplain Julia Allen Berger comments on "Chaplains in the Media." And she cites the Hastings Center's Bioethics Forum, where Nancy Berlinger, editor of the BioethicsWalk at PlainViews, has posted this interesting article providing some historical context.