Tuesday, March 31, 2009

Religious Coping, Medical Research, and the Popular Press: Updated

Updated 4-1-09

Regular readers may have already picked up on something that’s a major annoyance to me. I regularly get annoyed when the broadcast press (that is, aimed at the general public, whatever the medium) picks up on an article published in a major research publication. Most often, someone in the media has caught wind of an interesting article in a medical journal. Sometimes, it’s because someone associated with the study thought that the added attention would be good for the research effort (usually, in terms of public interest and/or increased funding).

In any case, I usually find that the folks who made the research public usually get something wrong. Perhaps they talk about hope for a medical breakthrough, while the study in question only hints that something like that might be possible a decade or so from now, if all goes right. Perhaps they make sweeping generalizations based on a small pilot study. Most often, the researchers try hard to qualify the information, and to make clear the limitations. Sometimes they’re complicit in the problem, more concerned about getting their point out than about being as accurate as possible.

The case in point was pointed out at by a colleague, one of the editors at Episcopal Cafe. First, he discovered an article in the March 18th Boston Globe with the sensational headline, “Religious dying patients more likely to get aggressive care.” Then, he discovered a related article in The Economist, titled “But not yet, Lord.” Both articles were reporting on an article in the March 18 edition of JAMA, the Journal of the American Medical Association, titled, “Religious Coping and Use of Intensive Life-Prolonging Care Near Death in Patients with Advanced Cancer” (Phelps, Andrea C, et al: JAMA. 2009; 301(11):1148-1154). Both the Globe and Economist articles hit home at the same point: that “religious” patients used more care at the end of life, suggesting that being “religious” was the cause of the demand for more intervention.

I have now had a chance to read the JAMA article closely, and have some comments to make. First, the Globe headline is simply inaccurate. The study used a specific instrument to measure religious approaches used by patients in coping with terminal illness. The instrument incorporated techniques labeled by those who developed the tool (good people, by the way) as either "positive" or "negative" - as either helpful or not helpful in coping. This study did not look at people who were "more" or "less" religious. It looked at people who used more or fewer of the "positive" religious coping techniques (to no small extent, because almost no participant used "negative" techniques). So, it was not whether participants were "more" or "less" religious, but whether religious participants did or did not use particular techniques. The JAMA authors themselves wrote,

Our findings should not be misinterpreted as denying the experience of many patients who find peaceful acceptance of death and pursue comfort-centered care because of their religious faith. Although religious coping is a theoretically appealing measure of functional religiousness, we can not say that positive religious coping rather than other religious factors (e.g. religiously based morals) completely accounts for the association observed.

In fact this is a concern about the RCOPE, the instrument used to distinguish those who used positive religious coping from those who did not. In the article, “The Many Methods of Religious Coping: Development and initial validation of the RCOPE” (Journal of Clinical Psychology, Vol. 56 (4): 519-543 [2000]; cited by Phelps et al in the JAMA article), Pargament, Koenig, and Perez note

Several limitations and remaining questions deserve some discussion. First, the results of the present analyses are cross-sectional and therefore do not permit causal inferences. While the methods of religious coping may have affected adjustment, it is also possible that different levels of adjustment elicited different forms and levels of religious coping….

It is also important to consider whether methods of religious coping work in similar ways for different people faces with different life stressors.

Since the RCOPE was given when patients entered the study, and perhaps well before facing the difficult decisions at the end of life, it could be argued that the life stressors at diagnosis of a terminal disease might be different from those when finally approaching death itself. Certainly, contra the conclusion misstated in the Glove and Economist articles, it is not clear that we can infer that greater use of positive religious coping, much less “being more religious” has any causal connection to the decisions to use more medical care at the end of life.

Let me comment further on the study itself. To begin with, let me note one piece that the Economist article got right: “More than 11% of those with the highest scores underwent mechanical ventilation; less than 4% of those with the lowest did so. For resuscitation the figures were 7% and 2%” Those are certainly statistically significant differences. However, they also point to the complementary statistics: that in the study group, among those with high religious coping scores 88% did not undergo mechanical ventilation, and 93% did not receive resuscitation. So, one has to wonder about differences between the 88-plus percent vs. the 11-plus percent, or between the 93% and the 7%, and what made the difference for them. Since both had high scores for positive religious coping, that may not be the determining factor.

That significant differences might still be of interest if the results of the study group could reasonably be generalized to all patients. However, I have some significant concerns about the study group. Phelps et all note that

"Positive religious coping was significantly associated with being black or Hispanic. Patients with a high level of positive religious coping were younger, less educated, less likely to be insured, less likely to be married, and more likely to be recruited from the Texas sites.

These facts are worth noting. Black and Hispanic patients quite frequently have a hard time trusting both the intent and the content of the health care they receive, based on long history of inequitable care. They can often express concerns that health care providers will “give up too soon.” Families of young patients often hold out hope, reflecting a tendency in our culture to cherish our children, and to favor those with a future over those with a past – even when, as for these patients, it is the future they should have had, and not the future they or their families wished. In their abstract the authors say that their findings are significant “after adjusting for age and race.” However, they are not that explicit in the article itself. Moreover, even if that is the case, these are important enough and well enough known medical social issues that they should have been addressed in the article.

I also want to note the comment that “Patients with a high level of positive religious coping were… more likely to be recruited from the Texas sites.” In fact 78% of those with a high level of positive religious coping (138 of 177), and 55% of all participants (181 of 345) were recruited at two sites in Dallas, Texas. While this is indeed a multicenter study, with participants from sites in Massachusetts, Connecticut, and New Hampshire, in addition to the Dallas sites, the participants could hardly be considered equitably distributed. The article does not consider whether there might be significant cultural and community differences between Dallas and the Northeast that might affect the outcome.

By the same token, 55% of those with a high level of positive religious coping (98 of 178) were either Baptist or Protestant, while only 26% of those with a low level of positive religious coping (43 of 167) were in those categories. Conversely, 45% of those with a high level of positive religious coping were Catholic, Protestant, or Other (80 of 178); while 74% of those with a low level of positive religious coping (124 of 167). This suggests that there may be significant theological differences among the demographic subgroups that affected the results on the RCOPE. In their discussion, Phelps et all comment that

Intrinsic to positive religious coping is the idea of collaborating with God to overcome illness and positive transformation through suffering. Sensing a religious purpose to suffering may enable patients to endure more invasive and painful therapy at the end of life. Alternatively, religious copers might feel they are abandoning a spiritual calling as they transition from fighting cancer to accepting the limitations of medicine and preparing for death. Religious patients might thus equate palliative care to “giving up on God [before he has] given up on them.” Qualitative studies commonly report spiritual reasons for preferring life-sustaining treatments, including a belief that only God knows a patient’s time to die. Finally, high rates of intensive end-of-life care among religious copers may be attributable to religiously informed moral positions that place high value on prolonging life.

They do not, however, consider how differences within their study group might have been attributable to such dynamics as these.

Also, let’s think again about the comment that “Patients with a high level of positive religious coping were younger, [and] less educated….” In my recent post reflecting on Do Not Resuscitate orders, and whether Allow Natural Death orders would be an improvement, I noted that a critical piece in care at the end of life is clear communication about the limitations of therapeutic medicine, and about changing goals of treatment from therapy to palliation – from cure to comfort. Combining issues of youth and education with cultural and language issues (issues that may well have been relevant for some Hispanic subjects) identifies points where that communication is more difficult, and at which patients and/or their families might misunderstand and resist changing the goals of care. I acknowledge that these patients all had received already a terminal diagnosis. That in and of itself doesn’t guarantee that all those in a critical position for decision making were of the same mind, or understood the patient’s needs and prognosis in the same way.

Finally, I have a concern that rises from the bibliography with the JAMA article. There is no evidence of review of the literature available in pastoral care publications. While regular readers will know this is a common concern of mine – that we don’t read each others’ literature – with a subject such as religious coping one might have expected some use of the literature of those professionals whose area of expertise is religious coping in health care. This is not to disparage the articles they cite. They do use, as noted, work from Koenig, Pargament, and Larson, who have contributed significantly to information about the interactions of religious behavior and health outcomes. At the same time, a thorough literature search might well have resulted in citations from the Journal of Pastoral Care and Counseling, the Journal of Healthcare Chaplaincy, or Chaplaincy Today.

And so, an interesting study that could have been better prepared and discussed was picked up by the popular press; and when the popular press got their hands on it they stretched the results well beyond what the original researchers had suggested. For me this is a particularly egregious example, because it strays into my own professional experience. However, it’s another example of a common occurrence: that the popular press takes one medical study and finds in it results that aren’t really there, or that have to be qualified far more than the popular press is interested in doing. I don’t suppose we’ll ever stop it. That doesn’t mean we don’t need to challenge it whenever it happens.

Update: An article has appeared now in the popular press challenging the JAMA article. Dr. Kate Scannell, a contributor to InsideBayArea.com wrote Faith, hope, and clarity at the end of life. Dr. Scannell noted an additional concern about the preponderence of participants from Texas: Texas is the one state with a medical futility law that can under certain circumstances allow a hospital to remove a patient from life support without family permission. As Dr. Scannell noted, "It's certainly conceivable that dying patients receiving care in those institutions might make unique medical decisions that fend against the perceived threat of being denied care." (And thanks to the blog Practical Bioethics for pointing to Dr. Scannell's article.)

Friday, March 27, 2009

General Convention 2009: Let's Get It Started

It's hard to think about it, but I've been at this blogging business for three years.  That's meant a lot of time at the keyboard.  I've enjoyed it, even if I've had my down times.  Still, it helps to be opinionated.

One of the ways I'm conscious that it's been three years is that General Convention is coming up again.  One of the reasons I began to blog was that I felt that things were done and said at General Convention that most Episcopalians never heard about, much less thought about.  So, one of the tasks I had was to begin writing about issues to addressed at the 2006 Convention, and about issues that had been addressed there or at previous Conventions.

Well, I still feel that way, and here we are with another Convention rolling around.  Today the Blue Book, the collection of reports and proposed resolutions from commissions, committees, agencies, and boards of the Episcopal Church, was released.  You can read the Episcopal News Story about that here.  You can access the reports themselves here.

I encourage you to look at the various committees and read some of the reports.  I've begun doing that, and you should begin seeing the results of my reading soon. 

So, watch this space.  General Convention convenes again this July.  So much to prepare!  So much to talk about!

Wednesday, March 25, 2009

Choosing the Right Words

So, the Church of Nigeria – Anglican has officially recognized the new ecclesial entity, the Anglican Church in North America (ACNA). Well, we knew that was coming, didn’t we? The fellow travelers have been working hard at this and saying it was coming for some time now. The Church of Nigeria has considered communion with the Episcopal Church “broken” for some time now; and changes made to their constitution in 2005 simply codified that, if implicitly. Their efforts at missionary work in the United States, which in part laid the foundation for the ACNA, demonstrated that they felt there was no relationship with the Episcopal Church to be injured. So, now they have confirmed their effort to support this new body, which is intended to replace the Episcopal Church, in their esteem if not in any institutional sense.

So what should we say to these things? What should we say now that what has been predicted, even desired for some time, has now come to pass?

Nothing. To this, right now? Nothing.

It’s not that this doesn’t annoy me. It annoys me as it annoys many. I’m as annoyed as anyone when partisans suggest that I’m not Anglican, or even Christian. I’m annoyed when partisans proclaim the 700 or so congregations and 100,000 or so total members in such a way as to suggest that all were once Episcopalians, and that all – congregations and members together – have all left the Episcopal Church since General Convention in 2003. I’m not saying that none have. I am saying that most of those congregations, and many of that 100,000 were never Episcopalian; and many of those who were left long before, over Prayer Book and ordination of women.

But, we’ve known this was coming. We’ve known it at least since the Hope and a Future Conference of the Anglican Communion Network in November, 2005. In that gathering Henry Orombi called for the participants to “come out,” saying, “We will support you.” Peter Akinola said, essentially, “What are you waiting for?” And Robert Duncan said, “There’s no way for these two conflicted faiths to live under the same roof.” Sure, they took more time than I expected – more, too, I think than they expected. But we’ve known it was coming.

And, it doesn’t really have that much of an effect on us. That is, I think most of those who will leave the Episcopal Church have already left the Episcopal Church. Periodically, I read someone who speaks of hosts leaving, or of the Episcopal Church “bleeding out;” but it’s basically rhetorical excess. Instead, we have a new church institution on the block – and, since ACNA wants to incorporate some of the smaller groups that left over the past 40 or so years, perhaps that will result in fewer institutional structure, rather than more. As regrettable as some might find it (including the Archbishop of Canterbury), the Anglican tradition in North America is entering a state like the Orthodox tradition in North America: a variety of churches representing different facets of the same tradition, nominally acknowledging one another (which is better than some of the active sniping of the past) and going about their business. For a generation and more there have been churches calling themselves Anglican, existing initially in contradistinction with the Episcopal Church; and after some tension at first, having little or no impact on the Episcopal Church. A generation or more hence our successors will likely see this in much the same way.

Oh, there are some property disputes to settle, and plenty of rhetoric to exchange, but those will pass. Undeniably, the relationships among the national and provincial churches that now make up the Anglican Communion will change; but we will all adjust. Eventually, all of us on all sides will discover that we have something more important to be concerned about, something that speaks more to our sense of mission than fractiousness and fragmentation within the Anglican tradition.

Now, some things will indeed be harder in the short term. I’m going to be particularly interested to see just what Archbishop Williams says this summer to the General Convention about the Covenant he so desires. With this much damage already done, and a strong sense among some here that his attitude of “institutional communion at all costs” has largely contributed to this, the Covenant may be a hard sell.

But what should we say to this event?

Nothing. At this point, there’s nothing new, nothing shocking, and really, nothing to say.

Well, except, “God be with them, and with us. God be with us all.”

Monday, March 23, 2009

DNR and AND Orders: How Not to Do Too Much

Last week one of the administrators in my hospital came to my office. The topic: was it appropriate for a particular patient to have written a “Do Not Resuscitate” or “DNR” order? And, if such an order were written, should that affect the plan for care for the patient in question?

That isn’t an unusual question in health care, nor in my practice. Until recently I had been for years the Chair of our hospital’s Ethics Committee, and I still serve on it. I also provide education for nursing staff on Health Care Treatment Directives, Durable Powers of Attorney for Health Care, and Do Not Resuscitate orders, and how our policies direct their use.

And in fact the issue was already bouncing around in my mind. I had recently run across an online article from USA Today, titled “'Do not resuscitate' vs. 'allow natural death'” There has been discussion for some time in health care about changing the phrase “Do Not Resuscitate” to “Allow Natural Death.” The USA Today article discussed the topic, especially in light of research published last year suggesting that, all other things being equal, families and perhaps patients themselves would be more comfortable making a difficult decision at the end of life if the decision was phrased as “allowing natural death” instead of “withholding resuscitation.”

The research article, “’Allow natural death’ vs. ‘do not resuscitate:’ three words that can change a life,” was published in January of last year (Venneman et al, Journal of Medical Ethics, 34 (1), pp. 2-6). The authors were themselves interested in this question. They noted that words are emotionally laden, and some phrases more laden than others. They also noted that people made decisions differently under emotional stress than when not under stress. Their central concerns were that the phrase, “do not resuscitate,” being stated in the negative (“do not”) could be heard as threatening in tone, and that those hearing it as threatening would make decisions about a patient’s health care based on the emotional reaction instead of on a clear discussion of the patient’s needs and the limitations of medical care.

So, to check this out they put together a study. They decided to put together a survey. They also wondered whether it would make a difference how much education and experience one had relevant to DNR orders. They thought, too, that nurses should be considered because in actual events nurses are very much involved in carrying out DNR orders, and in discussing them with and explaining them to families. So, they surveyed three groups to consider different levels of experience: experienced nurses in practice; nursing students; and a non-nursing control group. Each participant was given a written scenario about a near-death experience, which included definitions of the medical terminology in the scenario. They were asked to consider the scenario as for a member of the participant’s family. They were then asked to mark an analogue scale (0 to 100%) as to the probability that the participant would consent either to a “Do Not Resuscitate” order or an “Allow Natural Death” order. They also recorded some demographic information about participants.

The results of the study were that in all three groups participants were more likely to consent for a loved one to an order of “Allow Natural Death” than to an order of “Do Not Resuscitate.” There was also a difference according to levels of education and experience. While experienced nurses, those most likely to understand the orders in either form, were more likely to agree to AND than to DNR, the difference was not great. However, among both nursing students and the non-nursing control group the difference was significant; and more significant among the non-nursing control group than among the nursing students. They also noted that demographic “variables of gender, ethnicity and religious affiliation did not significantly impact endorsement. AND was statistically more likely to be endorsed even controlling for these variables.”

In their conclusion Venneman et al stated, “Increased support of the order through changing the title [from DNR to AND] should decrease tension and conflict during the consent. This would result in decreased emotion and therefore enhanced communication.” They also suggested, “Using the term AND should help eliminate difficulties in interpretation resulting from phrasing the directive in the negative “do not” and decrease negative semantic reaction, allowing all involved parties to focus the actual outcome of the order.”

This article did stimulate a response article. The article, titled “’Allow Natural Death’ is not equivalent to ‘do not resuscitate’: a response,” was published in December, 2008 (Chen and Youngner, Journal of Medical Ethics, 34 (12), pp. 887-888). Drs. Chen and Youngner challenged both assumptions and conclusions of Venneman et al. They suggest that, while DNR might be “more negative” than AND, the precipitating situation is not: the limits of what medicine can do are being reached. At that point they suggest that understanding and communications are less dependent on emotion-laden terms than on clear communication in discussion with physicians.

They also suggest that AND may not be less confusing than DNR in that AND is focused on a specific, expected, and unavoidable result: the patient’s death. DNR, on the other hand, may be appropriate if a patient would not want the rigorous efforts of chest compressions and electric shock in the event of an arrest, but who still has the possibility of some therapeutic or palliative benefit. Thus, a DNR order does not automatically imply that a patient is terminal, much less that the plan of care is for comfort measures only. However, they point to studies that suggest that “healthcare professionals tend to provide less medical care to DNR patients than to those patients without DNR orders.” So, while DNR and AND are not really interchangeable, there may be a tendency for healthcare professionals to act as if DNR were in fact AND. If so, providers might not discuss with patients and/or families the full range of possible treatments and their respective benefits and risks.

Finally, Chen and Youngner challenge the interpretation of the results of the survey. Specifically, they note that among the practicing nurses the difference of choice between DNR and AND was not significant. Thus, they question whether there is really a desire among practicing professionals (either the practicing nurses who were surveyed, or among doctors, who were not) to replace DNR with AND.

As a chaplain I have been aware for some time of the discussion about changing from DNR orders to AND orders. That desire has certainly come from a concern among chaplains, and others, that families may not hear clearly, and certainly have trouble accepting, when the therapeutic limits of medicine have been reached. In that instance, would it be clearer to present as appropriate the decision to “allow natural death?” If death is unavoidable, it might well be more appropriate, independent of the thought that it might be easier to hear and accept.

When thought through, it becomes clear that the two terms are not really interchangeable; and the differences can be important. Venneman et al are certainly correct in noting that the DNR and AND are semantically different; but they may not make clear just how different they are. Chen and Youngner are correct in noting that AND is focused on, and indeed is explicit about, an unavoidable death. Yet, in the circumstances of a hospital just how “natural” is such a death? In fact care does not end at that point. Instead, it changes. While therapeutic benefit – curing, healing – might no longer be possible, care continues for palliative benefit. Death, then, may well not be “natural” in the sense that things don’t just stop; but it may well be better than “natural” in that the resources of care continue, with the intent changed to preserving comfort.

On the other hand, “do not resuscitate” certainly is a “negative” order. As my Best Beloved observed as we discussed it, it implies that resuscitation is normative, and the new order not to resuscitate is the exception. If therapeutic benefit is still the goal of care, an exceptional event might justify an exceptional order. So, an elderly patient might well hope the orthopedic surgery will be successful, and still not want heroic measures if in the process the patient suffers a massive stroke. At the same time, death is normative, sooner or later. Yet, without good communication from the physician(s) that there’s no therapeutic benefit left to offer, how is a patient and/or family to accept the “exceptional” order?

Moreover, in so many cases aggressive resuscitation is the last thing that professionals want to inflict; and I use the word “inflict” advisedly. Chest compressions can and do break fragile ribs, and too often pierce lungs. Electric shock is a visible physical shock to the body. In the situation where best medical advice is that it will not succeed, doctors and nurses don’t want to do CPR under the rubric of “first, do no harm.” Doctors will frequently press a family for a DNR order, even when the family has not yet understood that we’ve reached the limits of medicine, simply to avoid treating the patient in a way the professionals see as explicitly harmful.

Friday, March 20, 2009

On the Business Journalist

At our house we’re fans of both John Stewart and Jim Cramer. After all, they’re not as different as they seem.

So, you can imagine we watched last week the made-for-television back and forth between them. It started with Stewart’s satirical critique of punditry at CNBC, and culminated in the interview of Cramer on Stewart’s show. We watched it all; and while we also appreciated that, first, the critique was about business journalism in general, and CNBC in particular, and so it was, as Stewart said, “unfortunate” that Cramer had become the face of it; for Cramer had gone out on a limb more than once trying to advise his beloved “home gamers” appropriately. Second, Cramer in the interview did try to take what he would call “the high road,” not getting into a fight, but trying to respond quietly, and where he felt he should, apologetically.

That said, I was disappointed, then, by Cramer’s comments yesterday on the Today Show. He said it was really misinformed to say that business journalists “had caused” the economic crisis.

I was disappointed, because that’s not what Stewart said. What Stewart said was that it was an important part of the role of a journalist to be skeptical about sources. What he meant when he said that he wanted Cramer the business journalist to protect him from Cramer the hedge fund manager was that, if Cramer wanted to be considered a journalist, being investigative was an essential part of the job.

Now, I have to say I have a certain skepticism in general about “business journalism” on the cable channels – or, more accurately, about “journalism” on the cable channels. I don’t think of, and don’t usually speak of those channels as “news channels,” their chosen names notwithstanding. I think of them as Opinion and Editorial Channels – Op-Ed Channels, or perhaps now Punditry Channels. That’s because I find little news on them. I find little new information, and lots of opinions. Now, sometimes those assertions are identified as opinions, and sometimes their asserted as if they were facts; except, facts have sources that can be acknowledged, even if the acknowledgement is as vague as “the folks I’ve been talking to.”

CNBC is as much a Punditry Channel as any of the rest of them. Jim Cramer is a pundit. Now, he also does some journalism. He does on his shows share information that would be hard for his “home gamers” to ferret out. However, the bulk of his show is punditry, his educated opinion, expressed for the interest of his audience. I certainly believe he wants to do well by his audience. I believe his audience is a lot broader than most of his colleagues on CNBC, who seem to be talking only to other folks in the investment industry. I believe his principles, and especially his own principle of not taking anyone’s opinions – even his own - uncritically when making financial decisions, are good principles.

That’s why I was disappointed that he didn’t get it. Stewart’s challenge wasn’t about whether business journalists had caused the economic crisis. It was about the group as a whole leaning so into their connections with business that they failed to be skeptical and investigative as journalists. And it is that very skepticism and investigation that would provide the rest of us with real news, really new information, and so enable us to make the kind of good, careful decisions that Cramer himself advises.

Monday, March 09, 2009

Brief Note for 3.9.09: Politics

Most of those blathering these days about "socialism" don't really know anything more about "socialism" than they know about the internal workings of an atomic bomb.  What they know about both is that if you throw them around you can expect big explosions, which makes them ideal to scare a lot of people.

And in another brief thought, my Best Beloved asked me recently, "Have all those folks who want to connect Christianity and capitalism just never read those parts of the Bible about how the early Christians gave "from each according to his ability to each according to his need?"  (Hint: for those who haven't, read the Acts of the Apostles.)  Of course, if your purpose is not to use capitalism to justify Christianity, but rather to use Christianity to justify capitalism....

More Food for Thought at the Episcopal Cafe

My newest piece is up at the Episcopal Cafe. You can read it here. Perhaps we can say it comes from watching all those cooking and cooking competition shows on cable. However, the issue is what we think is the purpose of God's gift of communion when expressed in the Anglican Communion.

On a related note, if you'd be interested in my take on where Archbishop Williams wants to take the Anglican Communion, you might look here and here and here and here.

Tuesday, March 03, 2009

Worker Sisters/Worker Brothers Lenten Quiet Day: 3rd Reflection

I had the honor this year of leading the Lenten Quiet Day for Worker Sisters of the Holy Spirit and Worker Brothers of the Holy Spirit in the Kansas City area. The Worker Sisters and Worker Brothers are a Christian Community recognized in, and with membership well beyond the Episcopal Church. The theme of study for this year has been about strengthening Christian faith through interreligious dialog. This was the third reflection for the Quiet Day.

And What of Those Who Don’t Want to Follow a Jew?

I have said that there were those who denied the Jewish heritage in the Christian tradition. The most important and perhaps most dangerous such a person was the heretic Marcion.

Marcion was the son of a bishop in Asia Minor. Most evidence is that he was not ordained himself. Instead, he was something of a shipping magnate. He is reported to have had a falling out with his father, perhaps over a sex scandal; and about 139 A.D. he moved to Rome. To establish a place for himself in the Roman church, he is said to have donated 200,000 sesterces to the congregation.

Marcion had a very dualistic sense of the world, focused less on “Good and Evil” per se than on “Law vs. Gospel.” He studied with Gnostics in Rome, although some of his beliefs differed from most Gnostics.
  • He believed that there were two gods, the God proclaimed by the Jews, who was committed to Law and Justice; and the “Unknown God,” who was committed to Love and Grace. The God of the Jews was the creator of the world and all matter, which was corrupt and evil. That God was violent and could be brutal. The “Unknown God” was the Father who sent Jesus Christ. He loved all and saved by grace – although it was salvation from bondage in law and sin, and not a promise of resurrection.
  • He couldn’t believe in the Incarnation. He couldn’t believe that Jesus had been born, because that would make him material, and make him subject to the God of the Jews. Instead, Jesus was a “manifestation:” visible, but not material.
  • He accepted Paul’s writings, especially where he proclaimed Grace and condemned Law. Because the Jewish tradition in the Old Testament was the story of the God of Law, Marcion rejected it entirely.
  • In fact, Marcion basically rejected any Scriptures Christians used that he thought were too accepting of, too corrupted by the Jewish tradition. For use by him and his followers he produced his own “Bible.” It consisted of a Gospel, based on Luke, and ten of Paul’s letters. For the book he cut out a lot, and even added a little, to eliminate anything too Jewish and to reinforce his belief.

In 144 the Roman church threw Marcion out. They even returned the 200,000 sesterces. He returned to Asia Minor and started his own church. While it wasn’t terribly important in the Western part of the Empire, in the East it was a serious competitor with the orthodox catholic Church and lasted for almost 150 years.

The success of Marcion provoked the Church to a reaction. That’s not to say that there was in those days a single institution that we might call “the Church” as we imagine it today. Instead, orthodox and catholic bishops wrote to one another and shared writings. There were local councils, and important writers wrote critiques of Marcion’s practices. Over time, they reached consensus on some important matters.

  • They affirmed that the God Jesus proclaimed, whom Jesus made incarnate among us, was the God of Abraham, Isaac, and Jacob, the God proclaimed by the Jews.
    o So, there was only One God, whom Jesus called Father, in both Old Testament and New.
    o The Old Testament, and those new Testament writings that reflected and affirmed the heritage of the Old Testament, were also inspired by God and could be used as Scripture.
    o So, Jesus was fully human, as the author of Hebrews said, “in every was as we are, but without sin.”Jesus was not displacing the Old Covenant, Instead, he fulfilled it so that he could offer the new Covenant of grace.
  • To be as consistent in faith and practice as Marcion sought to be, Christians came to consensus about a body of literature, the foundation of what we now know as the Bible.
    o It included the Old Testament in the Septuagint, its Greek version.
    o It also affirmed all the books thought to be written by Apostles, and not only by Paul. That included the four Gospels we have received, and the letters of James, Jude, and John. They were believed to have been written by Apostles or by their disciples (so, Mark and Hebrews), and this was confirmed by content consistent with the faith as the Churches had received it.
    o That included even those writings that some then (and later) might have considered “too Jewish,” including Hebrews and the Letter of James.

With the ultimate failure of the Marcionite church, the consensus and ultimate canonization of the New Testament as we have it, and the thorough incorporation of our Jewish heritage in our faith and worship, we might think this matter was settled. However, it continues to be a concern that we need to address.

  • How often have we heard, even in our own time, that dichotomy that God in the Old Testament is all Law, Justice, and Punishment, while God in the New Testament, as seen in Christ, is all Love, Grace, and Salvation?
  • How recently was it that the Roman Catholic Church apologized for centuries of anti-Semitism, and stopped thinking of Jews as “Christ killers?”
  • We need to recognize that even as great a theologian and scholar as Luther, who went to a rabbi to learn Hebrew to study the Old Testament, was still prone to see the Letter of James as “too Jewish,” to focused on works; and to express anger that the Jews would not see that the Messiah had already come in Jesus. We need to recognize that those sentiments have not disappeared, even if they are spoken less openly.

So, what does it mean for us now to appreciate the Jewish heritage of Christianity? What do we think is the most significant contribution of our Jewish heritage to our Christian faith? What new insights have we had this morning, and what new behaviors might those insights suggest? And where might we want to go from here in honoring the Jewish heritage in the Christian faith?

Monday, March 02, 2009

Worker Sisters/Worker Brothers Lenten Quiet Day: 2nd Reflection

I had the honor this year of leading the Lenten Quiet Day for Worker Sisters of the Holy Spirit and Worker Brothers of the Holy Spirit in the Kansas City area. The Worker Sisters and Worker Brothers are a Christian Community recognized in, and with membership well beyond the Episcopal Church. The theme of study for this year has been about strengthening Christian faith through interreligious dialog. This was the second reflection for the Quiet Day.

The Lord’s Prayer is a Jewish Prayer

Years ago, during one of my residencies in clinical pastoral education, one of my fellow students and good friends was a rabbi. She was a good student, and a good chaplain, and an enthusiastic participant in all the activities of the Pastoral Care department.

Well, all but one. She struggled with participation in worship. This was a Lutheran hospital, and she was the first non-Christian student they had ever had in the program. No one wanted to exclude her, and she didn’t want to be excluded; but as a Jew, and more particularly as a Rabbi, a representative Jew, she had some difficulties with participation – especially with the expectation of participation – in Christian worship.

Of course, not with everything: she said, “ I don’t have a problem with the Lord’s Prayer. There’s nothing in that prayer that a Jew couldn’t say. The only problem with the Lord’s Prayer is the Christian understanding that Jesus is the Lord.”

Jesus was a Jew; and when he prayed, he prayed as a Jew. He led Jews, and when he taught them to pray he taught them to pray as Jews. He taught them the Lord’s Prayer. (Matthew 6:9-13; Luke 11:1-4)

That thought may come as a bit of a surprise. We think of the Lord’s Prayer as Jesus’, and as ours; and it is ours. Jesus taught it when disciples asked him how to pray.

At the same time, there is nothing distinctively Christian about it, or there wasn’t when he taught it (remember, our departure from our Jewish forebears comes after the resurrection, and not before).

  • There is honor to the Father, but no reference to the Son.
  • There is a call for God’s Kingdom, but no suggestion that Jesus was bringing it in, as there is in Luke’s account of Jesus in the synagogue in Capernaum.
  • There is prayer for God’s grace, but none for, say, our resurrection.

When scholars look at the Lord’s Prayer, they see this even more clearly. We think of Jesus’ address to God as Abba, “Father,” as distinctive; but in fact it was already known in the Hebrew Scriptures and in early synagogue prayers. There is a remarkable parallel between the various clauses of the Lord’s Prayer and a prayer long central to synagogue worship, the Amidah, also known as the Shemonah esre, “the Eighteen Blessings.” In that prayer God’s Name is declared holy, and there are prayers for the coming of the Messianic kingdom, for daily needs, prayers asking forgiveness and calling on the believer to forgive others. While Jewish scholars believe that the Amidah took on its current form in the generations after Jesus’ death, they believe that the separate prayers, and earlier versions of this prayer, were probably current long before.

The Lord’s Prayer has become central to all of our prayer, both in public worship and private devotion. But it is not the only prayer from our Jewish heritage that has become so central.

Consider the Psalms. For certainly the Psalms are prayers. We think of them more as hymns, chanted in public worship; and certainly many of them were. However, are not our hymns also prayers? For, as St. Augustine said, “For he who sings praise, does not only praise, but also praises joyfully; he who sings praise, not only sings, but also loves Him whom he is singing about. There is a praise-filled public proclamation in the praise of someone who is confessing, in the song of the lover (there is) love.” So, when one sings one’s prayers, one might accomplish more than one thing. Thus, the statement has come down to us in the distorted form of, “He who sings (or sings well) prays twice.”

We still hold that hymns are prayers. Thus we have a hymnal, and the hymnal of the Episcopal Church must be approved by General Convention. That’s not to say that we can’t use music outside what’s in the Hymnal; we can. But the Hymnal sets the standard of what the content should be of our hymns, whether we use those approved by Convention or from another source. The Hymnal sets the standard of the theology we express in worship; and so, like the Prayer Book, it must be approved by General Convention.

So, the Psalms are indeed prayers, some for public worship and some for private devotion, that have come to us from our Jewish heritage. And it is no surprise that they should have come down. For the first Christians were largely Jewish, or familiar with Jewish worship. Remember that the first Gentiles to embrace the faith were “God-fearers,” pagans who had embraced the One God as proclaimed by the Jewish people, without formally converting. They attended synagogue worship, even though they sat outside the sanctuary itself. Thus, whether Jew or Gentile, the first Christians were familiar with the chanting of the Psalms. Regular chanting of psalms continues to be an aspect of Jewish worship and devotion.

This is also important for us in Christian Communities and Orders. In his Rule, on which our various specific rules are based, St. Benedict quotes extensively from Scripture to justify his provisions. He quotes more from the Psalms than perhaps from any other portion of Scripture. Indeed, he considered them so important that he so arranged the Offices, the times of prayer during the monastic day, that the entire body of Psalms was read through every week. For each office there might be a portion of another part of Scripture – usually a brief passage, at most a few verses - but always a long portion of the Psalms.

And look how important the Psalms have become for our worship. In the Book of Common Prayer it is virtually impossible to find a public service or private devotion that does not incorporate some portion of the Psalter. Even the brief "Daily Devotions for Families" incorporate some small portion. Certainly, the Eucharist and the Daily Offices call for portions of the Psalms. We are not as rigorous as Benedict’s early monks. The Daily Office Lectionary repeats the Psalms through a period of about seven weeks; and within the Psalter itself in the Prayer Book there is a guide to read through them in thirty days instead of seven. The Order of the Holy Cross, of which I am an Associate, completes the Psalms over fourteen days, and then leaves out the unpleasant parts. However, extensive and repeated reading of the Psalms is central to the rules of professed religious and their associates and oblates in the Episcopal Church and the Anglican tradition.

And yet, why have they become so central? Like the Lord’s Prayer, we do not find the distinctive beliefs of the Christian faith in the Psalms. There is proclamation of the Messiah, but it relates more to the kingship of David and his descendents than to God the Son. There is some suggestion of resurrection, but not through the Messiah.

And there is so much in the Psalms that makes us uncomfortable – the bitter, angry, nasty parts. That’s why the Monastic Breviary of the Order of the Holy Cross has excluded certain passages. There is great violence in the Psalms. There are cursing and brutality in the Psalms, and cries of abandonment by God. Jesus himself, in his most desperate hour, quoted perhaps the most tragic verse in the Psalms: “My God, my God, why have you forsaken me?” (Psalm 22:1)

And yet I think that is why we continue to chant and to value the Psalms. They help us to proclaim the full range of our human feelings, and to share them in our relationships with God. For what sort of relationship is it that focuses on only the good stuff, the happy times? Our experience as human beings is not only good and happy. Sometimes it is indeed unpleasant, ugly, and violent. We would say a relationship that could not also incorporate those experiences was shallow, lacking in intimacy; and if we would say that of a human relationship, how much more true must it be of our relationship with God? Yes, God does indeed see and know all of that in our lives; but if we have not offered to God those parts of our lives, we have not really offered ourselves wholly to God. How shall we lay on God our troubles, if we’re not willing to share them even with God? That was true in ancient Israel, and it is true today.

And, like so much of the Hebrew Scriptures, we look at them through the lens of our Christian experience. And so, we see in the Psalms references to the Messiah as we know him, even if they who originally wrote them did not see those references. They are a part of our Jewish heritage that illuminates our Christian experience.

And so, what are these aspects of our Jewish heritage to us as individual Christians? What does it mean to us that these central prayers, the Lord’s Prayer and the Psalms, are both so Jewish and yet so pertinent? How to we appreciate these as aspects of our worship now? And how do they connect us to the experiences of the early Church, both those who walked with Jesus and the subsequent generations?

Sunday, March 01, 2009

Worker Sisters/Worker Brothers Lenten Quiet Day: 1st Reflection

I had the honor this year of leading the Lenten Quiet Day for Worker Sisters of the Holy Spirit and Worker Brothers of the Holy Spirit in the Kansas City area. The Worker Sisters and Worker Brothers are a Christian Community recognized in, and with membership well beyond the Episcopal Church. The theme of study for this year has been about strengthening Christian faith through interreligious dialog. This was the first reflection for the Quiet Day.

The topic for February is “Jewish Prayer and Worship.” However, if this is not to be an abstract, academic exercise, we need to go a step further: what are Jewish prayer and worship to us?

So, let us begin at the beginning. Jesus was a Jew. Or, as one example of T-shirt theology has it, “My master is a Jewish carpenter.”

There are those who have tried to assert otherwise. There are those who have asserted that because he was the Christ he had to be a Christian, and couldn’t be a Jew. They do that, really, out of an intent to reject anything Jewish than a commitment to Scripture or to the faith as we have received it. For the evidence is clear, and affirmed by Christian and Jewish scholar alike: Jesus was a Jew.

We can say that with comfort based on the witness of the Gospels.

  • Matthew and Luke alike, for all the differences in their Birth Narratives, agree that Jesus was a descendent of David. (Matthew 1:1-18; Luke 3:23-38)
  • Luke asserts that Joseph and Mary followed established Torah rituals after his birth: circumcision on the eighth day, and a sacrifice of redemption on the fortieth. (Luke 2: 21-24)
  • Through his childhood his parents participated in the major Temple festivals. (Luke 2:41)

Jesus was raised a Jew, the son of Jewish parents.

He continued to be a Jew as an adult.

  • According to John he continued himself to participate in the annual Temple festivals. (John 2:13; 5:1; 7:2,10)
  • He was recognized in his home synagogue, not simply as a reader but as a rabbi, qualified to teach on the Scriptures he read. (Mark 1:21-22; Luke 4:16-21)
  • Indeed, he was not infrequently addressed as, “Rabbi.” (John 4:31)
  • He quoted the Hebrew Scriptures readily, and reflected on them. Think especially of the how often he says in the Sermon on the Mount, “You have heard that it was said in ancient times…. But I say to you….” This was reflection, not on social custom, but on Torah and on past interpretations of Torah. (Matthew 5:21-48)
  • Indeed, in the same context he says, “I have come not to abolish [the Law] but to fulfil [it].” (Matthew 5:17)
  • His last and most important gathering with the disciples came in the context of the Passover, either as a seder, or as a chaburah meal for the eve of the Sabbath.

That is not to say that Jesus didn’t have an interesting relationship to Torah. He was more concerned with the intent, or more specifically, God’s intent as expressed in Torah.

  • So, many scholars have suggested that Jesus affirmed the Law, the Torah, and then expected believers to exceed it. So, he called for his hearers to “righteousness [that] exceeds the scribes and the Pharisees.” (Matthew 5:17-20)
  • When he allows his disciples to gather grain, essentially to harvest, on the Sabbath, he points to David’s use of bread dedicated to sacrifice to instead feed his troops. (Matthew 12:1-4)
  • When he eats with sinners, which he apparently does quite often, he speaks not of purity but of outreach. (Matthew 9:9-13)
  • He calls the Pharisees and scribes “whitewashed tombs,” beautiful on the outside but dead and corrupt on the inside, for being all style and no substance (Matthew 23:27-28)
  • And so he says to do as the scribes and Pharisees instruct, but not as they do; for “They tie up heavy burdens, hard to bear,* and lay them on the shoulders of others; but they themselves are unwilling to lift a finger to move them.” (Matthew 23:4)

Remember especially the tradition of the Pharisees: in Torah, and in reflection on Torah, they had discerned more than 600 separate laws that the observant Jew was expected to follow. To do that, one practically had to be a person of leisure. The poor didn’t have the time or the resources to really meet that standard.

  • So, when Jesus said, “It is easier for a camel to go through the eye of a needle than for a rich man to get into heaven,” his disciples responded, “Then, who can be saved?” (Matthew 19:24-25)
  • Blessedly, we are saved by grace; and so Jesus said, “For mortals it is impossible, but for God all things are possible.”

In fact, Jesus was oriented specifically toward those who could not meet those standards. The early rabbis spoke of a group or class of Jews called ‘Am ha-aretz. The phrase translates, “People of the Land,” or “People of the Earth;” but it was used to speak of those were poor and working class, and particularly that they had neither the education or the resources to be “good” Jews according to Pharisaic standards. Those were the “poor” whose backs bore burdens prescribed by the Pharisees: burdens of performance to the extent they could, and burdens of shame when they failed.

So, Jesus was a Jew – born and raised and practicing as an adult. He knew and affirmed the Law, even as he called his listeners to God’s purpose in it, instead of to scrupulous attention to detail. So, what does this mean for us as Christians, who are not Jews? What does Jesus’ Jewish heritage and practice mean for us? And what does it mean for us, both as individuals and as the Church, that he came not to abrogate Torah, but to fulfill it?