Friday, May 30, 2008

Back to St. Andrew's 6

This is the next step on the St. Andrew’s Draft.

The next questions put to Deputies spoke to the Appendix of the St. Andrew’s Draft, which proposes in greater detail some possible mechanisms to accomplish the resolution south in Section 3.2.

Appendix: Section 3.2.5 b & c of the Draft Covenant assume a schedule of procedures that are intended o accompany the Covenant. The Appendix provides a draft framework outlining procedures for the resolution of disagreement.
• Should our possible agreement to a Covenant be contingent on subscribing to a set of procedures for addressing disagreements in the Anglican Communion. If so, is this draft framework (the Appendix) helpful?
• Do you see an emerging set of canons for the Anglican Communion in this Appendix? If so, is this beneficial or not to the Anglican Communion at this time?

The appendix is four pages, and so, once again, I won’t try to copy it for this comment. However, I don’t think I need it to answer, and even to answer concisely.

Let’s first consider the question of whether we our participation in a Covenant should be “contingent on subscribing to a set of procedures.” Certainly, such a set of procedures would be an innovation, one that has been described often enough as being at least as great as American understandings on human sexuality. Some would respond that the current situation itself is new for the Communion. We have, after all, managed for some time with a “gentlemen’s agreement,” without really challenging whether we were as uniform as we appeared. Still, even if we don’t jump to the conclusion that this innovation is wrong, and that “two wrongs can’t make a right,” we would need to consider whether the innovation of a defined process, and especially one that might “resolve” an issue by institutional divorce, is a good idea.

The Windsor Report spoke of a process of reception, and used as a model the adaptation of the Communion to the ordination of women. In fact many of us believe the Windsor Report glossed magnificently over the difficulties of that reception process; and the current difficulties in the Church of England over ordination of women to the episcopate demonstrate pointedly that “reception” in this instance has hardly resulted in “resolution.” However, “reception” is a model that acknowledges autonomy while still maintaining relationships within the Communion. It is a evolutionary process, far too slow for its critics on both ends of the spectrum. However, it is a way – perhaps the only way, really – to describe how, within our current structure (or lack of it) we can discuss issues at length, see how they are lived out or not in our various contexts, consider how the Spirit might be leading us, and come to consensus. It incorporates the statements of the Instruments of Communion (notwithstanding the recent assertions of authority of the newest Instrument, the Primates Meeting), while recognizing the limited and largely attributed authority those statements have.

The consequence of accepting such a scheme as is laid out in this Appendix would be to significantly to change the nature of the Communion. If, as I said in my last post on the subject, we haven’t done the hard work of explicating the ecclesiology on which we can agree, I don’t think we do well to accept a scheme that assumes an ecclesiology to which we haven’t all agreed. To make our participation contingent on accepting these processes is to preempt our own work, and any conversation we might have with our Anglican kin, about that ecclesiology.

That does indeed suggest to me that this offers a new, if partial, set of canons for the Communion. Again, we haven’t really agreed that a consistent set of canons is desirable (although it arguably has support from Canterbury). Even if we were to agree, once again I think we would want to start with a consensus on ecclesiology instead of with means of resolving issues.

Are there positive things to be said about the processes offered in the Appendix? I think there are. I appreciate the focus on the office of the Archbishop of Canterbury and the Anglican Consultative Council instead of the Primates Meeting. I appreciate that several different means are offered to seek reconciliation, including mediation.

At the same time, two of the four “routes” explicitly present time frames that would certainly be problematic for the constitutional processes of the Episcopal Church, a matter I have written of already; and a third implies much the same. Ultimately, too, this creates an authority for the Archbishop of Canterbury measurably beyond the “primacy of love” that his office has held in the past for the Communion outside the Church of England.

In any case, my concern still remains that this Appendix is premature. It assumes agreement on matters of authority and church structure that we have yet to reach.

We have committed in General Convention to participate in and monitor closely the Windsor Process, which so far has included discussion of an Anglican Covenant. It seems, however, that the false urgency of current disagreements are encouraging some to work toward paper agreements that lack firm footing in our understanding of what it means to be the Church in the Anglican Communion. Acceptance of this Appendix would establish (and the current Draft Covenant, even without this Appendix, risks establishing) an ecclesiology by fiat, one that we haven’t discussed at length among provinces, nor accepted by constitutional processes within provinces. We need to make that effort first. We need to take the time, even if it takes a generation, to do this right, beginning with articulating the ecclesiology we have with all its variations, and determining where the Spirit is calling us in allowing our ecclesiology to develop. If we are to understand what it means to us to be the Church in the Anglican Communion, we need to do that first; and once we’ve done that well, the form and content of our agreements, whether or not that includes a Covenant, should be abundantly clear.

Thursday, May 29, 2008

Back to St. Andrew's 5

So, the questions on the St. Andrew’s Draft of the Draft Anglican Covenant continue.

The next question for Deputies is

Section 3.2: Here the covenant focuses on challenges to the Anglican Communion. The voice changes from descriptive of our common life to proscriptive direction of how to proceed when our common life is threatened.
• Do you think it is necessary to articulate processes when communion is threatened and, if so, do you find these processes of consultation and conversation as outlined in 3.2 useful?

These questions address the Commitments related in “Section 3: Our Unity and Common Life” in the St. Andrew’s Draft. This is a long and detailed section, and so I won’t copy it in full. However, you can read it, along with the rest of the Draft, here.

The question posed is really two questions, and they’re important enough to consider separately. The first is, “Do you think it necessary to articulate processes when communion is threatened?” Yes, probably; but that begs an additional question. That is, why ask about circumstances “when communion is threatened,” and why not “when the Communion is threatened?” That makes a significant difference. After all, we experience communion at a number of levels (not to mention in a variety of ways; but that’s a post for another day), and each of those levels has a different structure. At each of those levels (parochial, diocesan, provincial, Anglican Communion, and full-communion relationships - think Called to Common Mission with the ELCA) threats to communion have different consequences. We in the Episcopal Church, and siblings in the Province of Central Africa, are experiencing threats to Communion at the provincial level, with corollary consequences at diocesan and parochial levels. In both provinces those issues (while not the same issues) involve the positions of bishops, diocesan control of property, and divisions within congregations. Both, interestingly enough, involve whether the bishop and diocesan leadership are conforming to or confronting the society around them; and in both events reflect the current cultural experiences of social and political disagreement (and, yes, I am certainly glad to be in a country where this has participants in court instead of in the hospital).

On the other hand, whether either of these difficulties is a “threat to communion” at the level of the Communion depends less on the events than on reactions. So, responses to local cultural conditions in the United States and Canada (acknowledging and embracing our GLBT siblings) become threats to communion, while responses to local cultural conditions in Nigeria (church support for legislation to outlaw gatherings of citizens to discuss rights for GLBT persons) do not because some provinces choose to react while others do not.. If the Anglican Communion is, as the St. Andrew’s Draft says elsewhere, is “a worldwide family of interdependent churches” (2.1.2) or “autonomous-in-communion” (3.1.2), what constitutes a “threat to communion” is in the eyes of the beholder. None of these events within a province are structurally prescriptive for any other province. Thus, a “threat to communion” that has concrete consequences at other levels of our common life only threatens the Anglican Communion by our choice, and not because there are concrete structures or defined relationships to be injured.

If we speak of a “threat to communion” instead of a “threat to the Communion,” it is precisely because the structures of and relationships within the Communion are more than a little ad hoc. Section 3.2 of the Draft tries to give some definition in its first paragraphs:

(3.2.1) to have regard to the common good of the Communion in the exercise of its autonomy, and to support the work of the Instruments of Communion with the spiritual and material resources available to it;
(3.2.2) to respect the constitutional autonomy of all of the Churches of the Anglican Communion, while upholding the interdependent life and mutual responsibility of the Churches, and the responsibility of each to the Communion as a whole;
(3.2.3) to spend time with openness and patience in matters of theological debate and reflection to listen, pray and study with one another in order to discern the will of God. Such prayer, study and debate is an essential feature of the life of the Church as its seeks to be led by the Spirit into all truth and to proclaim the Gospel afresh in each generation. Some issues, which are perceived as controversial or new when they arise, may well evoke a deeper understanding of the implications of God’s revelation to us; others may prove to be distractions or even obstacles to the faith: all therefore need to be tested by shared discernment in the life of the Church.
(3.2.4) to seek with other Churches, through the Communion’s shared councils, a common mind about matters understood to be of essential concern, consistent with the Scriptures, common standards of faith, and the canon law of our churches.

And so there is some assertion that with the Communion there is some sense of “common good,” which is itself supported if we “support the work of the Instruments of Communion.” At the same time, there is a sort of duality in the next sentences that may be either a “yes, but” or a “both/and.” There is “constitutional autonomy of all of the Churches,” with “interdependent life and mutual responsibility.” There is to be “openness and patience in matters of theological debate,” while the goal is to “seek... a common mind.” Play with these, and you quickly recognize that whether this is a “yes, but” or a “both/and” makes a great deal of difference.

That brings me, then, to the question of the specific steps for addressing a “threat to communion” described under section 3.2.5. In 3.2.5 and its subsequent details, each church commits

(3.2.5) to act with diligence, care and caution in respect to actions, either proposed or enacted, at a provincial or local level, which, in its own view or the expressed view of any Province or in the view of any one of the Instruments of Communion, are deemed to threaten the unity of the Communion and the effectiveness or credibility of its mission....

While there are angels (and others) in the details, there is a major headache in the possibility that “any Province or... any one of the Instruments of Communion” might raise an issue, and so interfere with mission even at a local level. We have for some time cherished the possibility that not only the Episcopate but also our “common worship” might be “locally adapted,” per the Chicago/Lambeth Quadrilateral. Between the two, we have been willing to see the goals and methods of mission be locally adapted as well. The possibility that “any Province or... any one of the Instruments of Communion” might call for wider discernment on aspects of local adaptation, and enjoin (whether successfully or not) mission is problematic, to say the least. Indeed, we have seen that displayed often enough in the history of world missions. Too often European or American missionaries have seen it important to convert not only to the Christian faith but also to European or American cultural and social norms.

So, back to the question: “Do you think it is necessary to articulate processes when communion is threatened and, if so, do you find these processes of consultation and conversation as outlined in 3.2 useful?” Yes, I do think it necessary to articulate processes for consultation and conversation when communion is threatened. I think those processes need to be appropriate to the specific details of the structures and relationships relevant to the level within our common life at which the threat is perceived. Unfortunately, the undefined (some would say “gloriously undefined”) relationships between provinces within the Communion make any specific processes, including those in 3.2.5, questionable. Some allege that the Episcopal Church didn’t do the theological work that would explain and support full inclusion of GLBT persons. (I don’t think they’ve been paying attention; but that’s neither here nor there.) I would suggest that the provinces and Instruments of the Anglican Communion haven’t done the theological work to really describe our ecclesiology. Until that done, until we’ve come to a common mind on what we mean by “autonomy-in-communion” with its “constitutional autonomy, interdependent life, and mutual responsibility,” we can’t really define what constitutes a threat to communion, much less what processes should be in place to address it.

Just a few more to go....

Wednesday, May 28, 2008

Blogging the CPE Experience, 2008

I met today with new summer interns in our health system's Clinical Pastoral Education (CPE) program. One of them will be coming to get his or her clinical experience in my hospital, and this was our opportunity to meet. I had a chance to describe my hospital, and to give them some sense of who I am (which may or may not help someone decide to come work with me). I also shared with them that thirty years ago I was myself off for my seminary- and church-required first unit of CPE. They're excited, and scared, and I remember enough to empathize.

Once again, I'm going to be looking for CPE students who are blogging their experiences. I'll check in as I can, and make encouraging comments as I can. I've started a list below of sites I've found, and I'll edit to add sites as I can.

May God bless them all, and provide them the experience this summer that will best support and build their ministries. And remember: there are no bad experiences in CPE. There are good experiences, and good learning experiences.

Law And Gospel



Seminary life

The Truth Will Make You Odd

And for a different view, follow Alan, a Resident in Supervisory CPE, at abayye. He's been blogging aspects of his CPE experience for some time now. As both a Supervisory Resident and a rabbi, he brings a different perspective, one that taps different sources in our Abrahamic tradition.

Thursday, May 22, 2008

Back to St. Andrew's 4

I've been asked to submit my comments on Section 2 of the St. Andrew's Draft for publication elsewhere. Therefore, I'm going on to the questions on Section 3.

So, here is the next question for Deputies about the St. Andrew's Draft of the Draft Anglican Covenant:

Section 3: This section describes some of the elements of our common life together in baptism, Eucharist and ministry and moves to elaborate more recent understandings of our life in the Anglican Communion. It identifies ways by which the Anglican Communion comes together and then describes the four Instruments of Communion in their appropriate historical development.

• What meaning and impact do the four Instruments of Communion have for you in your diocese?

This is a question that has little to do with the content of the St. Andrew's Draft, and much to do with the need for a Covenant. Those who sense little awareness within a diocese of the Instruments of Communion might also have little interest in, much less commitment to, a Covenant process.

In a sense, I'm not the best person (or, at least, not the most representative person) to answer the question. I'm a blogger and an information junkie. I have particular interest in international relations. I expect I'm a lot more interested in these questions than most.

As a frequent supply priest, I find I get few questions about international issues in the Communion. That may mean they aren't interested. It may mean they have already had opportunities to discuss this with their own clergy. It may mean their clergy haven't kept them informed about events in the Church, even those events within the Episcopal Church that have international ramifications.

It is this last that is an ongoing concern of mine. Part of the reason for my blog is to highlight events, and especially actions of General Convention, that many folks may not know about. That they don't know is, in my opinion, commonly a fault of the clergy. Granted, it's easy enough for all involved to get caught up in parochial concerns, in both the literal and metaphorical senses. However, we do have a responsibility as clergy to educate congregations about the Anglican tradition, which should include some information about the Anglican Communion. (At least, that seems obvious to me.)

With that rant completed, let me give my impression. I think that within my diocese folks are aware of international connections in ministry. They are aware primarily of current and former companion diocese relationships, and of any current or continuing ministries from those relationships. Within my diocese, none of those ministries have been disrupted by the current troubles. I think there is some awareness of the Instruments of Communion when an issue makes the news. So, there is some awareness of the Archbishop of Canterbury and perhaps of the Primates Meeting. There may be some current awareness of the Lameth Conference; again, it's been getting some press as it gets closer. I fear there is hardly any awareness of the Anglican Consultative Council at all.

Also relevant to the question is my thought that even if folks are aware of any or each of the Instruments, I don't think they're aware of the relations among them (it's not really as mysterious as the interrelations of the Trinity; but they've heard more sermons on the Trinity). When most of the information comes from headlines, they all appear authoritative, and perhaps equally authoritative.

In that light, the St. Andrew's Draft is significantly better in paragraph 3.1 than the Nassau Draft in describing the role of each of the Instruments of Communion. I appreciate listing of the Instruments in order of their establishment, clarifying that the Anglican Consultative Council predates the Primates Meeting. I particularly appreciate the description of the Primates meeting that reflects its original purpose, without the accretions of assumed authority so blatant in recent years.

So, to return to the question: I'm not sure just how aware people are of the Instruments of Communion, or how much impact of the Instruments they feel. But, then, I find myself once again wondering about the question. The impact, if not the intended import of this question, is less about how much parishioners know and more about how much deputies should care. How much awareness of and sense of presence of the Instruments is beneficial within the Episcopal Church? Like, and not unrelated to, the question of bishops, is the Communion of the esse, the bene esse, or the pleni esse of the Church? How much are the Instruments of the esse, the bene esse, or of the pleni esse of the Communion (for example, would it be possible to have something we would consider a Communion without one or more)? How we answer those questions would say much about our interest in and perceived need for an Anglican Covenant; and if we are interested, what it ought to include.

And now, on to the next question....

Tuesday, May 20, 2008

More Good Stuff on the Radio

Yesterday was an interesting day for a chaplain’s ears. I heard two interviews that I would like to call to your attention. As will not surprise regular readers, both were from NPR, my most common news source.

The first was on Fresh Air. There host Terry Gross interviewed the Rev. Carroll Pickett. For 13 years Pickett was the death-house chaplain at the Walls prison in Huntsville, Texas, where he ministered to inmates executed by lethal injection. What caught my attention early in the interview was the fact that after each execution he recorded his thoughts and experiences on tape. He did it as a means of self-care, based on his own experience in CPE; and the reference to CPE caught my attention. The interview is about 40 minutes, but it’s well worth the time. (Chaplain Pickett was also interviewed for the 1999 Frontline episode, “The Execution.” You can find a transcript of that interview here.)

Later in the day I caught a portion of All Things Considered in which Melissa Block interviewed Chinese Christians and clergy in the area of the recent earthquake. She asked the clergy how they cared for their parishioners, and how they discussed the earthquake. It was a classic discussion of the problem of suffering; and as one who has to address that problem with some frequency, I was interested in their responses. Take some time, and hear for yourself.

Monday, May 19, 2008

Donation Difficulties: More on San Luis Obispo

I have written before of the case of a transplant physician in San Luis Obispo, California, alleged to have acted inappropriately in the death of a patient eligible for donation after cardiac death. There is an update to the story here.

The initial allegations included concern that the doctor involved had affected the patient’s diagnosis of severe brain injury and/or the family’s decision to donate organs. Reportedly the physician was not involved in either of those decisions. The concern remains as to whether he hastened the patient’s death.

It’s important in understanding this to distinguish donation after brain death, our common expectation, from donation after cardiac death. You can read a good description of brain death here, but the basic information is that brain death is a diagnosis that the brain, from top to bottom (and in this case, “bottom” is important) has ceased to function. The brain has been so injured that not only is the damage not recoverable, but also the most basic, noncognitive functions of the brain have ceased. I say “bottom” is important because those most basic functions take place in the brain stem, that portion of the brain that connects brain functions to other parts of the body. A number of important functions connect there that don’t require thought, including especially breathing and some significant reflexes.

Note that I didn’t include heart function among those of the brain stem. The heart can function quite well on its own, as long as sufficient nutrition and oxygen are available. That’s why for many brain death is hard to see: the patient is on a ventilator, lungs being mechanically (and passively) pumped with air. Family members see the chest rise and fall. What they don’t necessarily realize is that the patient’s brain has nothing to do with that; it’s all the machine. At the same time, it’s enough to sustain the heart – for quite a long time, if not forever. Indeed, one of the definitive tests for brain death is an apnea (“not breathing”) test. The patient’s tube is disconnected from the machine, and physician and staff watch to see if that most basic reflex, the drive to breathe as carbon dioxide builds up in the blood, kicks in. They don’t wait forever, as it were; but they wait quite long enough to demonstrate that the patient’s brain cannot do that job. The apnea test isn’t the only test done, but it is quite significant.

So, the point of brain death is that the brain is so damaged that the patient would already be dead if it weren’t for the machinery pumping air into the body. As a result, brain death is one legal definition of death. The patient is considered legally dead from the time the diagnosis is confirmed and recorded by the physician.

Now, the decision has to be made independent of consideration of transplant. The standard of care is to have the decision made if possible by a neurologist or neurosurgeon; but certainly by a physician not involved with any transplant program.

But, what about patients who are so severely brain injured that best medical advice is that the patient cannot survive, but who are not brain dead? It’s possible for all but the brain stem to be injured so badly that the patient will die eventually, without affecting the functions of the brain stem. Such patients may be eligible for donation after cardiac death (also known as non-heart beating donation).

Once again, a decision needs to be made independent of any consideration of donation. In this case, the decision is the family's decision about whether and when to withdraw life support and allow natural death. If the patient is severely brained injured beyond hope of recovery, and the family decides to withdraw support, the patient may be eligible to donate.

Hospitals have procedures regarding donation after cardiac death. (They have to; having policies and procedures to participate in donation activities is a requirement for Medicare reimbursement.) If the patient is eligible to donate and the family consents, a team is assembled and a schedule prepared. When the family is ready, the patient is taken off the ventilator. The patient may be given medication for comfort, just as would happen if there would be no donation. The family and the team watch and wait with the patient until the patient stops breathing. There is a time limit (just how long varies from hospital to hospital), and if the patient doesn't stop breathing within the designated time, donation efforts end. The team continues to support patient and family while waiting for death to occur. If the patient does stop breathing within the designated time, the patient is taken to surgery. There the team stops for another five minute “hands off” period, just to be sure the patient doesn’t spontaneously breathe again. If after that time the patient has still not started again to breathe, the team proceeds with recovery of organs for transplant.

According to the article in, the online edition of American Medical News from the AMA, the physician in question was not involved either in the family’s decision to withdraw support or in the family’s consent to donation after cardiac death. Instead, he was a member of the transplant team, present to follow through once the patient had died. However, he was apparently involved in caring for the patient after the ventilator had been withdrawn. During that time he gave the patient morphine. The allegations are that in doing so he inappropriately hastened the patient’s death.

Determining whether the morphine was appropriate, and whether it hastened the death, would seem straightforward. In fact it might not be. The allegation is based in part on the amount of morphine ordered. According to the article a number of physicians testified that in their opinions the doses were excessive; while a number of other witnesses testified that the patient did not seem to be in distress.

At the same time, and without taking a position in this case, such decisions are not necessarily simple. There would be other factors to consider, and especially, whether the patient was “narcotic na├»ve,” or whether he had a history of receiving large doses of narcotics. Patients are unique, and patients who have long experience with relatively large doses might continue to need unusually large doses simply to maintain comfort. Distress, too, can be determined by several different measures. A patient who is severely brain injured may not be able to move or to grimace. Distress would then be measured by an accelerating heart rate or respiratory rate. That’s something that a monitor would show; but if the professional didn’t explain it, the nonprofessionals present might not make the connection – especially when they are, very appropriately, focused on the patient and not on the monitor screen.

It will be interesting to see how this case plays out. The first successful kidney transplant took place in 1954. With all the educational efforts made over the past fifty years, the number of patients who might benefit from the generosity of transplant continues to far exceed the number of organs donated (much less the number of families who choose to donate). When professionals are not circumspect, they add to doubts about transplant that many in society already feel. It is easy for those in health care to see the generosity of donation and the benefits to organ recipients, and lose track of the concerns of families, and of the stresses they feel from simply from grief, without the further decision to donate. If the doubts in society, and the anxieties of grieving families are to be addressed appropriately and constructively, it is important for all who participate in donation programs to be sensitive, transparent, and careful.

Thursday, May 15, 2008

Who Speaks for the Patient?

Several years ago, there was this patient in the ICU. (Well, I suppose that could go without saying; but a story has to start somewhere.)

So, there was this patient. He had lived a hard life, with much of his adulthood (and probably much of his adolescence) spent addicted, enslaved to several different substances. In consequence, he had a number of different health problems. Now he had had a stroke. He had lived a hard life, and now it was coming to an end.

Or, at least it might have. This patient was, however, “unbefriended.” That’s the expression used in medical ethics discussions for the patient with no surrogate, no advocate. This patient was in one of those difficult cracks in our commitment to (almost worship of) the patient’s autonomy. He could not exercise his autonomy, and he had no one to exercise it for him.

Surrogacy is a corollary issue to autonomy. Autonomy is about the patient expressing his or her own wishes. We want to give care as best we can in conformity with the patient’s values. But, when the patient can’t express those wishes, we can be at a loss. So, we seek a person to act as surrogate for the patient. We hope the patient has an agent duly designated by a Durable Power of Attorney for Health Care. We expect the patient will have someone who fits into the various customary categories of “Next of Kin” (and, remarkably, those categories are more custom than regulation). But, here was a patient who, at first, seemed to have neither. What were we to do?

We had few options, and we didn’t really like those we had. We could seek a court-appointed guardian. However, court-appointed guardians had (and in many places still have) limited authority for health care decisions; and that did not include authority to discontinue care, even if futile. We could keep caring for him until he died despite our care. We thought that abusive of the patient, doing things to him that didn’t really benefit him; and we thought that abusive of another patient who could benefit from those procedures but wouldn’t receive them because he was receiving them. That would also, of course, be quite costly for the hospital. We could try to find some placement for him that Medicaid would provide, but we knew there were almost none that would take a patient with as many medical issues as he had.

With all that, it’s no surprise we were grateful when the patient had a visitor. The patient couldn’t respond enough to appreciate him, but we certainly could. He was a former friend, a person who had gone through rehab with the patient, and had lived with him for a while in a residential aftercare facility. When the patient had relapsed, the friend had stayed sober, and they had drifted apart. Still, he was someone who knew something about the patient.

In fact, he knew two things. First, he and the patient had in fact discussed health care, and had discussed how much extraordinary care each would be willing to accept. He had heard the patient say that he wouldn’t want to be maintained indefinitely if there were no hope. And second, he knew that the patient had a sister, and he knew what town she lived in. She and the patient had not spoken in a decade or more, largely due to the addiction. Still, we had someone to look for, and we were able to find her.

So, who should speak for this patient? Those of us providing care were not in a position to speak for him. We had no clue what he might want, and only our own opinions (informed, perhaps, but still opinions) about what harmed him and what served his best interest. We could seek a guardian, but that person would know no more than we did, and would have legally limited authority in deciding about the patient’s care. The real choice – at least, the choice that might meaningfully serve and represent the patient – was between the ex-friend who knew him, and the sister whose authority everyone could recognize. So, who should speak for the patient?

In preferring autonomy to other issues, and especially non-maleficence (“first, do no harm”) and beneficence (“act in the patient’s best interest”), we have found ourselves in this position. This case was not as bad as it could be: the truly unbefriended patient leaves us with even fewer options. Still, it represented a dilemma between knowledge of the patient’s wishes without authority, and legal and moral authority to carry out wishes unknown. And because our categories and priorities of “next of kin” are more customary than statutory, the same issues obtain, and can become complicated, in patients with large but conflicted families. Sometimes the child has been raised by grandma, but mother, estranged or struggling or addicted or some combination thereof, is still the immediate parent. Sometimes four adult children have four different opinions. I once cared for a patient visited by four women: his wife, his mother, his ex-wife, and his current girlfriend (the permutations of that were interesting!). Barring a clear Durable Power of Attorney for Health Care (and some people can manage to make even those unclear), we can struggle with the question: who is the best person to speak for the patient?

In this case, we were blessed, and so was the patient. The estranged sister was comfortable with the information provided by the exfriend. She approved – indeed, she virtually delegated her authority to – the decisions of this person who could speak to what the patient would actually walk. She had lost her brother long ago, but she was still prepared to respect his wishes; and she was able to accept the report of those wishes from this exfriend. The patient was given measures for comfort, and was allowed to die naturally (or at least as naturally as modern medicine would allow by this time).

We all work most comfortably when there is a clear statement from the patient established with clear authority to act. When that’s not clear – when the patient is unbefriended, or when there are too many friends and family and too little clear information – we wrestle with how best to serve the patient. We can talk about futility, and policies and laws on futile care can make some things easier. But our overarching moral principle in health care is respect for the person. And when we don’t really have a person, an interacting moral agent, whose wishes we know and so can respect, we still struggle with the central question: who speaks for the patient?

Wednesday, May 14, 2008

Things Worth Reading

Let me call to your attention two new posts at Episcopal Cafe, neither of them mine. Andrew Gerns, a parish priest and former hospital chaplain, and a valued colleague, has written two posts on cost shifting in health care, and on the moral issues involved. You can read them here and here, and I encourage you to do so.

Andrew also has his own blog, "Andrew Plus;" and you can read that here.

Saturday, May 10, 2008

Back to St. Andrew's 3

Now, to the third question on the St. Andrew’s Draft.

This is the next question asked of General Convention Deputies reviewing the St, Andrew’s Draft of an Anglican Covenant:

II. Second Level of Engagement with the Text (continued)

Section 1.2: This section describes how the above historical affirmations are lived out in various contexts. It also speaks about the nature of authority at various levels.
• Does this section appropriately describe how you understand a) the authority of the Bible, and b) the exercise of episcope in The Episcopal Church?

So, let’s look at section 1.2:

1.2 In living out this inheritance of faith together in varying contexts, each Church of the Communion commits itself:

(1.2.1) to uphold and act in continuity and consonance with Scripture and the catholic and apostolic faith, order and tradition;

(1.2.2) to uphold and proclaim a pattern of Christian theological and moral reasoning and discipline that is rooted in and answerable to the teaching of Holy Scripture and the catholic tradition and that reflects the renewal of humanity and the whole created order through the death and resurrection of Christ and the holiness that in consequence God gives to, and requires from, his people;

(1.2.3) to seek in all things to uphold the solemn obligation to sustain Eucharistic communion, in accordance with existing canonical disciplines as we strive under God for the fuller realisation of the Communion of all Christians;

(1.2.4) to ensure that biblical texts are handled faithfully, respectfully, comprehensively and coherently, primarily through the teaching and initiative of bishops and synods, and building on habits and disciplines of Bible study across the Church and on rigorous scholarship, believing that scriptural revelation continues to illuminate and transform individuals, cultures and societies;

(1.2.5) nurture and respond to prophetic and faithful leadership in ministry and mission to equip God’s people to be courageous witnesses to the power of the Gospel in the world.

(1.2.6) pursue a common pilgrimage with other Churches of the Communion to discern the Truth, that peoples from all nations may truly be set free to receive the new and abundant life in the Lord Jesus Christ.

I actually find myself wondering about the first part of the question put to us as Deputies. This section says little explicit about “the authority of Scripture.” Sections 1.2.1 set as equivalent and apparently complementary “Scripture and the catholic and apostolic faith, order, and tradition.” Much more is made explicit in the Affirmations in Section 1 as it makes some reference to the Chicago/Lambeth Quadrilateral. The role of Scripture in Section 1 emphasizes Scripture “as containing all things necessary for salvation and as being the rule and ultimate standard of faith;” and I use the word “emphasizes” advisedly, feeling that the description that follows of the “catholic creeds” and the “historic formularies” marks both as subsidiary to and dependent on Scripture. The Commitments in Section 1.2 appears to assume that understanding of Scripture without restating it explicitly.

Now, if we understand the tone of Section 1 to follow through in Section 1.2, we can ask what it means “to uphold and act in continuity and consonance with Scripture and [its extension in] the catholic and apostolic faith, order and tradition;” or what “a pattern of Christian theological and moral reasoning and discipline that is rooted in and answerable to the teaching of Holy Scripture [extended in] the catholic tradition” might look like. However, I certainly agree that our Christian living (moral and otherwise) should be consonant with and rooted in Scripture, as well as in the Christian tradition; and that it should look toward “the renewal of humanity and the whole created order through the death and resurrection of Christ and the holiness that in consequence God gives to, and requires from, his people” (and work toward it, too, to whatever extent we are able to cooperate with God’s work in the world).

So, as I look back toward my concern about the question about Scripture, I find these commitments don’t speak to my understanding of the authority of Scripture to any great extent. To the extent I see questions from the Affirmations in Section 1, I have some concern. To the extent I continue to see the Christian faith, and our Anglican corner of it, rooted in and reflective of Scripture, I can agree with these Commitments in Section 1.2. That said, I would fear that these Commitments would continue our current discussions without resolving our current disagreements. I think we will need to consider further sections of the St. Andrew’s Draft to know more.

Now, looking at the second part of the question, that of episcope, there is more to work with. Explicitly, it is “primarily through the teaching and initiative of bishops and synods” that “biblical texts are handled faithfully, respectfully, comprehensively and coherently.” Other documents in recent years have emphasized the teaching ministry of bishops, and especially their role in overseeing appropriate interpretation of Scripture, and it is not a surprise to see it emphasized here.

However, there are other commitments that we have historically seen as particularly (though not exclusively, at least in the American Church) within the purview of bishops. First, upholding continuity, especially with the catholic and apostolic tradition, has been an essential function of the historic episcopate. Second, sustaining Eucharistic communion is centered in the office of the Bishop, not least inasmuch as the functions of baptizing and celebrating Eucharist are not inherent in the presbyterate but are rather delegated from the episcopate. Finally, nurturing and responding to “faithful and prophetic ministry” involves bishops, if, again, not bishops alone.

According to “An Outline of the Faith,” the catechism in the 1979 Book of Common Prayer,

The ministry of a bishop is to represent Christ and his Church, particularly as apostle, chief priest, and pastor of a diocese; to guard the faith, unity, and discipline of the whole Church; to proclaim the Word of God; to act in Christ’s name for the reconciliation of the world and the building up of the Church; and to ordain others to continue Christ’s ministry.

Interestingly enough, there is no explicit reference to interpreting Scripture per se, or to overseeing the interpretations of others. While I won’t quote in detail, the same is true of the 1979 rite for the ordination of a bishop. Granted, there is some implication of interpretation in the responsibilities “to guard the faith, unity, and discipline of the whole Church; [and] to proclaim the Word of God.” There is something closer in the ordination rite, where the bishop asked to commit to “boldly proclaim and interpret the Gospel of Christ, enlightening the minds and stirring up the conscience of your people.” The implication of this commitment seems more homiletic, however, than academic; for surely “interpreting the Gospel of Christ” is a broader activity that interpretation of Scripture per se. Moreover, we have no sense in the Episcopal Church of a bishop’s authority, much less responsibility, to offer an imprimatur.

It seems to me, then, that the Commitments in Section 1.2 differ from our current practice in the Episcopal Church in specifying interpreting of Scripture and overseeing the interpretations of others as explicit responsibilities of bishops. It would seem to imply, if not explicitly to add, the sort of “nihil obstat” and “imprimatur” authority that our bishops have not claimed. Over all, I think the description of the authority of the bishop isn’t that different; but this seems to me a difference that makes a difference. It seems to establish, or at least to presage some sense of an Anglican “magisterium,” with a defined content of official teachings to which all would subscribe, and for which bishops would be particularly responsible.

I have written before of differences between our contemporary Episcopal understanding of bishops and those in other Anglican provinces; and of the difficulties we might have in speaking of bishops ordained “for the whole Church.” The process to develop an Anglican covenant must surely address these differences. These Commitments have much we might agree with, with some difference focused largely on the importance of Scripture and who might interpret with authority. There is much we might agree with; but also much we still need to talk about.

Okay: so, what’s next?

Wednesday, May 07, 2008

Back to St. Andrew's 2

Having taken on the first level of engagement with the St. Andrew’s Draft of the Draft Covenant, let’s start on the second. The instructions begin,

II. Second Level of Engagement with the Text
This level offers a brief introduction to each major section of the Draft Covenant and then poses more in-depth questions for discussion:

Section 1: The document begins with four affirmations based on the Chicago-Lambeth Quadrilateral and then makes two affirmations based on liturgy and ecumenism.
Do you find these affirmations a sufficient statement that describes the inheritance of our faith?

First and foremost, then, we need to think about these affirmations

Section One: Our Inheritance of Faith

1.1 Each Church of the Communion affirms:

(1.1.1) its communion in the one, holy, catholic, and apostolic Church, worshipping the one true God, Father, Son, and Holy Spirit;

(1.1.2) that, reliant on the Holy Spirit, it professes the faith which is uniquely revealed in the Holy Scriptures of the Old and New Testaments as containing all things necessary for salvation and as being the rule and ultimate standard of faith, and which is set forth in the catholic creeds, and to which the historic formularies of the Church of England bear significant witness, which faith the Church is called upon to proclaim afresh in each generation;

(1.1.3) that it holds and duly administers the two sacraments ordained by Christ himself – Baptism and the Supper of the Lord – ministered with the unfailing use of Christ’s words of institution, and of the elements ordained by him;

(1.1.4) that it upholds the historic episcopate, locally adapted in the methods of its administration to the varying needs of the nations and peoples called of God into the unity of his Church;

(1.1.5) that our shared patterns of common prayer and liturgy form, sustain and nourish our worship of God and our faith and life together;

(1.1.6) that it participates in the apostolic mission of the whole people of God, and that this mission is shared with other Churches and traditions beyond this Covenant.

I have already written my concerns about item 1.1.2: that the reference to “the catholic creeds” does not describe with sufficient clarity, or with sufficient respect, the place of the Apostles’ and Nicene Creeds in the life of the Church (nor does it clarify whether the Athanasian Creed is to be included; but that’s another matter). Items 1.1.2, 1.1.3, and 1.1.4 are intended to reflect the Chicago-Lambeth Quadrilateral; but the specifics of 1.1.2 fail on that point. In the Quadrilateral as accepted in the Lambeth Conference, the Creeds are named and their roles in the life of the Church specified: “The Apostles’ Creed, as the Baptismal Symbol; and the Nicene Creed, as the sufficient statement of the Christian faith.” This notes that the Creeds have a life of their own in the Church, not in contradiction to Scripture, but with some distinction from Scripture. The reference to creeds in the Covenant Draft establishes that the Creeds are subsidiary to Scripture as “the rule and ultimate standard of faith,” for the faith “is set forth in the catholic creeds,” but without any sense that the Creeds represent some development of the faith beyond the Scriptural record. Indeed, if there seems too little distinction between Creeds and Scripture, there seems even less between the Creeds and the “significant witness” of the “historic formularies.”

If the Committee wished to reflect the Quadrilateral, why not do so in the form accepted by Lambeth? My speculation (and I grant that it is only that) is precisely that description of the Nicene Creed as “sufficient statement of the Christian faith.” This speaks powerfully to our concern about Scripture containing “all things necessary to salvation.” If the Creed is “sufficient statement of the Christian faith,” what is not in the Creed is arguably not necessary to salvation; for if anything additional were necessary, it would be included. For those who would prefer a more confessional than relational or structural covenant, this would be a particular issue. If the Nicene Creed is a sufficient statement, is there really need for anything more elaborate?

There is a further concern I have in focusing solely on the Quadrilateral in describing “our inheritance of faith.” The Quadrilateral was not originally understanding the Anglican tradition. Instead, it was something of a “least common denominator” description of catholic Christianity. It was accepted at Lambeth as “a basis on which approach may be by God’s blessing made towards Home Reunion.” The description of the Quadrilateral when originally accepted by the Episcopal House of Bishops was more detailed:

But furthermore, we do hereby affirm that the Christian unity . . . can be restored only by the return of all Christian communions to the principles of unity exemplified by the undivided Catholic Church during the first ages of its existence; which principles we believe to be the substantial deposit of Christian Faith and Order committed by Christ and his Apostles to the Church unto the end of the world, and therefore incapable of compromise or surrender by those who have been ordained to be its stewards and trustees for the common and equal benefit of all men.

As inherent parts of this sacred deposit, and therefore as essential to the restoration of unity among the divided branches of Christendom, we account the following,…

In essence, as originally conceived the Quadrilateral was a description of the basic characteristics of the Christian Church. (Although I said in my earlier post that is was a description of what it meant to be Christian, I think “description of the Church” is more accurate.) It is, of course, essential that we affirm what it means for us to be Church, to be catholic and apostolic (for our holiness is in the Spirit, and not ours to command; and oneness, or lack thereof, is all too clear). However, I wonder whether that is enough to affirm as “a sufficient statement that describes the inheritance of our faith.” The Introduction to the St. Andrew’s Draft speaks of the Anglican Communion having “a special charism and identity among the followers and servants of Jesus.” It seems to me that these affirmations, except in the slight reference to the “significant witness” to the faith of “the historic formularies,” don’t describe anything distinctively Anglican. They don’t identify or define a special charism or identity. Indeed, in a quick perusal of the commitments in Section One and the affirmations in “Section Two: The Life We Share With Others: Our Anglican Vocation,” I still don’t see anything distinguishing us as Anglicans among other catholic and apostolic Christians.

As I look through the rest of the Affirmations in Section One, I don’t see anything objectionable, even if I might have phrased things differently. At the same time, I find the distortion of the Quadrilateral, and specifically the role of the Creeds in our Anglican life; and the lack of anything distinctively Anglican, to be problematic. “Do you find these affirmations a sufficient statement that describes the inheritance of our faith?” As a Christian, yes; as an Anglican, no.

Now, on to the next question.

Monday, May 05, 2008

Food for Thought at Episcopal Cafe

Once again, I have a new post up at Episcopal Cafe. I hope you'll take the time to read it and respond. (You'll understand this title when you see the piece.)

Take some time, too, to view many of the other material there. With news, spiritual reflections, and art and video presentations, there's a lot at the Cafe to enjoy. We hope you'll read, mark, learn, inwardly digest, and talk back.

Sunday, May 04, 2008

Ethics in Emergency Medicine Research

You may have heard this week about research on artificial blood substitutes for emergency use. In an article published on the website of JAMA – the Journal of the American Medical Association, Charles Natanson, Sidney Wolfe, et al, publish a review of published and unpublished studies on synthetic blood products (Cell-Free Hemoglobin-Based Blood Substitutes), which determined that existing studies, taken together, suggest that these products were less safe than hoped.

The article reviews studies of different products from different companies. They were also tested in different conditions. Some tested in trauma situations, although most tested in surgical cases. Over all according to the authors of the review article, “Based on the available data, use of HBBSs is associated with a significantly increased risk of death and MI.” (myocardial infarction, or heart attack)

The interest in these products is very high. The possibility of a product that would support brain and body, but would have a long shelf life, and not require refrigeration, is exciting. It's particularly exciting to trauma surgeons in military hospitals abroad and trauma centers at home. It's also exciting to pharmaceutical companies: the company that succeeds stands to make a lot of money.

Research in emergency medicine is difficult, and particularly difficult ethically. First, patients are rarely able themselves to consent, and commonly family members are not available. Then, too, exposing a patient to an unproven therapy, when the risk to life is so great and a proven therapy exists is hard to justify. At the same time, if new procedures and products aren't tried, how is emergency medicine to improve? And these issues are especially important if the therapy needs to be offered in the "Golden Hour," whether in the field or in the hospital.

Researchers have tried various ways to address the various ethical issues. One method, and one used with at least one such product, was community consent. Researchers approached local governments, essentially asking them to consent on behalf of their citizens. As emergency services, and especially ambulance services, are matters of public health, there is some logic to approaching public officials on what is arguably a public good. At the same time, concerns remained about patient autonomy, and specifically about patients receiving experimental therapies who would have declined if they'd had the capacity to do so.

(There have been other means tried to address consent issues in Emergency Medicine research. Perhaps another time I'll write about my experience with neomorts.)

I have one concern about the article. The published article addresses worse outcomes; but, worse compared to what? All the studies appear to have been treatment studies; and, after all, it would be unethical, especially in the trauma studies, to accept patients without intent to treat. Certainly, adverse outcomes were more likely for those who received the synthetic product than for those who received blood products. However, these products are particularly intended for situations in which blood would be difficult, if not impossible, to maintain or provide. So, one question is whether adverse outcomes would be more likely for those who received the synthetic product than for those who received no oxygen-carrying product at all (synthetic or natural). It's an important question. While the blood supply in the United States is safe, and not currently in short supply, there are circumstances in which it is limited. Since those are specifically the circumstances for which the products are intended, it seems an important point.

However, the authors do have a significant point. If, as they suggest, the greater risk of research subjects was known as early as 2000, there is an important ethical concern in continuing to enter subjects into studies. It creates a situation where risks counterbalance benefits to patients.

These are matters worthy of attention. We want the best available emergency care, and to that end we want the best available emergency medicine research. Of course, "best available emergency medicine research" requires good processes, including a good consent process. In a way, I could wish we had simply waited a few weeks and considered the primary review article. This secondary article identifies important issues but doesn't provide enough detailed information. However, these issues are important. For these, and for other new products, we need to be attentive to protecting patient safety and patient rights. That's how we best protect all of us.