Friday, December 17, 2010

Resources on DNR, AND, and Advance Directives.

I received this comment on my previous post:

Rev. Scott: You're right to encourage people to complete an advance directive, and also right to note that few do. One reason is that, as you note, people are often unfamiliar with the medical and legal terms. Many people have found our Five Wishes advance directive is a way of both starting the conversation, designating a health care agent, and giving that person instruction on what is wanted or not wanted. There are over 15 million in national circulation, distributed by some 23,000 partner organizations including churches. Learn more at --Paul Malley, President, Aging with Dignity

Mr. Malley has pointed to one good resource, and I thought it worthwhile to link it, and a couple of others.

  • Five Wishes from Aging with Dignity.  Mr Malley has pointed to perhaps the best known single program nationwide for not only making decisions about health care, but actually thinking them through.
  • The Caring Conversations program of the Center for Practical Bioethics.  While I'm especially proud of the Kansas City-based Center for Practical Bioethics, the Center is nationally recognized in promoting advance directive planning. The Caring Conversations program makes available in print or for download a workbook and forms in English and Spanish, as well as specialized workbooks for young adults and for aging military veterans.
  • The Advance Directive page from Caring Conversations, a program of the National Hospice and Palliative Care Organization (NHPCO).  NHPCO is one of the best known organizations supporting hospice and palliative care in the United States.  A feature of their page is a list of links allowing the user to download forms acceptable in each of the fifty states and the District of Columbia.
While there are many good resources available - indeed, you can request forms from any health care institution that accepts Medicare, and probably from most that don't - these are from organizations that are widely known and respected.  Feel free to review these resources, learn from them, use them, and share them.  I appreciate Mr. Malley's comment, and absolutely agree: all of us, really, need to be informed about these issues, and to make and share our decisions before they become critical.

Wednesday, December 15, 2010

Further Consideration of DNR and AND Orders: Thoughts on Public (Lack of) Awareness

I have written before about Do Not Resuscitate (DNR) orders and a recent effort to reframe them as Allow Natural Death (AND) orders. Last week there was a post on the subject on a New York Times blog.

There wasn’t really anything new in the article itself. It does, however, cite a research article more recent than the two I cited in a post last year (here and here). In fact, this study was a replication of one that I cited. I think replicating studies is a good thing, and this one basically confirmed the earlier results. (The study had the limitation of being a convenience sample; but I did find it interesting that it included a detailed list of the religious preferences of participants, and that two Episcopalians participated.)

Being the wonk I can sometimes be, I also took the time to read all the comments on the article. Those comments were also interesting. While something of a convenience sample in its own right, the comments also confirmed my own experience in some ways I thought worth note.

When I reviewed the comments, there were 65. While there were some professionals (physicians, nurses, EMT’s, etc), most respondents were, at least from what was shared, were not healthcare professionals. Some, both professional and non-professional, related specific events that shaped their thoughts, but most did not. All addressed in one way or another, the medical terminology of DNR and AND, and whether or not one term was preferable. A few respondents even suggested other terms they thought might be more acceptable. Mine is not a scientific, or even a statistical analysis. However, I think some themes were visible that I think reflect the current state of affairs.

* First, folks in the lay community are confused about not only the terms DNR or AND, but the variety of ways that care at the end of life can be shaped. Folks out there have heard the various terms of DNR (and now AND), Living Will, Advance Directive, Health Care Treatment Directive, and Durable Power of Attorney (DPOA) for Health Care; but they don’t know the differences among them. This became clear from the number of folks who wrote about a patient “signing a DNR,” which does not apply to DNR or AND orders, but to Living Will and Health Care Directive documents. I can’t say I’m surprised that lay folk are confused about these distinctions. I educate nurses regularly about the differences.

One particular distinction that lay folk weren’t familiar with was that a DNR order (or an AND order) is in fact a very limited order. It applies when and if – and only when and if – there is a specific event that might call for CPR. It doesn’t affect the identified plan for care, whether the plan is to cure or to provide palliative or comfort care, unless such an event takes place. On the other hand, Living Wills and Health Care Directives offer directions that can shape care, and that apply in broader circumstances.

* A second theme is that the movement to develop Physician Orders for Life Sustaining Treatment (POLST) is spreading, and has legal standing in some states. Professionals among the respondents referred to various acronyms, but all were based on the POLST model. Like a Health Care Directive, a POLST-type document is completed by the patient before there is need. Like a DNR or AND order, a POLST-type document is completed with the assistance of a doctor or other advanced practice professional, and is a set of orders.  There is some reason to think that they will be the step beyond Health Care Directives, in that the patient's preferences have the force of medical orders.  On the other hand, they can be misunderstood.  It was efforts to get Medicare funding for the time physicians and others spend with patients to complete POLST-type documents that triggered all the misleading "death panel" talk during the buildup to the new health care law.

* Few respondents expressed concern about their own deaths, but a number expressed concern about the death of another. That is, some were concerned that care might be withdrawn inappropriately and prematurely, primarily because of Living Wills and Health Care Treatment Directives. I have long said that few people are afraid of being dead, but many are afraid of the dying process. This is something different, although not a surprise: fewer folks are anxious about their own deaths or decisions, and more are concerned about decisions made for others and/or by others.

This is also consistent with my experience. Family members struggle when asked to make decisions that change the goals of care from cure to comfort. The various forms of Advanced Directives are supposed to help with that, and they do. It is easier on a family member to hear and support, "This is the preference your loved one has expressed," than, "What do you think?" However, there are still folks who fear that doctors will slant their information and decisions based on personal bias and/or business concerns, including some who responded to the story.

I think these are important issues that need to be addressed through education. That includes education of lay folk, but also of professionals. While the professionals responding to this blog post knew their business, I encounter professionals who don’t, and so can’t properly inform or educate patients and families. Sometimes, too, the poor information causes them unnecessary ethical questions in the course of providing care (not to say that there aren’t necessary ethical questions; but some are also unnecessary).

As a chaplain, and especially as a chaplain long involved in clinical ethics in hospitals where I have worked, these points of confusion or lack of information make it harder than necessary to make decisions consonant with the wishes of patients and/or families, and harder than necessary to communicate the decisions we make. Even as we support patients’ rights to make in advance decisions about their health care – including decisions that are different from those we might make, or even approve of – we need to have our terms straight and our information clear. It won’t eliminate our fear of the dying process; but it may well make it easier for patients to tell us about the care they want, and for those of us providing and supporting care to work together to meet those wishes.

Tuesday, December 14, 2010

An Episcopal Perspective: Distinctions That Episcopal Chaplains Bring to Health Care Ministries

I wrote this article for Chaplair, the newsletter of the Assembly of Episcopal Healthcare Chaplains (AEHC). The latest issue of Chaplair is now in print, and so I feel free to also share the article here.

When I first began writing a blog four years ago, I had one topic that I especially wanted to think about. That is whether there might be an Episcopal culture for health care, comparable to the distinctive cultures of, say, Roman Catholics or Seventh-day Adventists.

As I wrote about it (for me, a way of thinking out loud), I identified some characteristics that I thought an Episcopal culture might include. For example, the General Convention has never given specific directives on health care procedures. We have made some clear statements, but not statements that somehow separated us within the larger health care community.

I haven’t given up on the concept of an Episcopal culture for health care, even though I don’t think I’ve found it yet. However, I do think some of the characteristics I have discerned do give the Episcopal Church something important to offer in chaplaincy, and for us to offer as Episcopal chaplains.

We are remarkably well prepared to work in the multicultural, multifaith, polyglot environment of contemporary health care. Central to this is our commitment to the Baptismal Covenant. We have embraced as definitive of the Christian life, and certainly of our Christian ministry, that we will serve Christ by serving all persons, and loving neighbor as self. We have claimed for ourselves that we will “strive for justice and peace among all people, “ and not just our own; and that we will “respect the dignity of every human being,” and not just those who agree with us. Certainly, all professional chaplains commit to these things in codes of ethics and professional standards. We, however, have declared this as fundamental to our faith and practice as Episcopalians.

We are also, I think, well prepared to speak of the eternal in a variety of images. This is in part because we embrace all of Scripture as meaningful, while recognizing that in Scripture God is described in many ways, and addressed in many titles. We have made this formative for us in how many of these titles have been reflected in the Book of Common Prayer. Consider the variety of attributions of God in the many Collects of the church year, both in the Collects for Sundays and in those of feast days. Think of the many titles of God provided in the Psalms. I find this variety makes it very straightforward for me to pray in multifaith groups in ways that respect both my listeners and my own faith.

We have an appreciation of the power of liturgy, of structured and familiar responses, in the most significant moments of life. We certainly know the reality of that for folks like us from “liturgical churches.” However, I think many, if not most of us, have experienced how true this also is for those who claim other traditions. Once again, the Book of Common Prayer is a resource. Even when our words are not the appropriate words per se, we have experience structuring words and phrases to express the concerns and feelings of those in crisis. And, how many of us have discovered a chaplain colleague from another tradition making use of the Book of Common Prayer in her or his own professional practice?

As AEHC has gathered over the years I have advocated that we chaplains claim our place in the church. Many have heard me say, “As we are the Episcopalians among the health care chaplains, we are also the health care chaplains in the Episcopal Church.” It is also the case, however, that we are the Episcopalians among the health care chaplains. We have not defined our presence in our society to any extent by distinctive positions on medical practices. We do, however, bring tools and perspectives to health care chaplaincy that allow us to standout among our colleagues, and to serve patients, families, and staff from many traditions.

Saturday, December 04, 2010

The Power of Words, Even in Our Own Voices

I had an interesting experience yesterday.  On a whim, I attended a monthly meeting of the Grief Support Network.  This is a great local organization, with an excellent web site and resources.  There is a monthly meeting with a speaker, and the topics are always interesting.  However, I can’t usually go.  I have a standing meeting at the hospital at a conflicting time, one that I can’t miss.  Yesterday the meeting was cancelled, and I decided to take advantage of the opportunity.

The topic was “forgiveness,” and especially forgiving oneself.  As a part of the presentation, the speaker passed out a “mirror script” – that is, a set of affirmations one might read to oneself.  By reading the affirmations while looking in a mirror, one can get something of the experience of hearing them from another person, adding a sense of visible presence to hearing the words.  Since we didn’t have mirrors in the meeting, the speaker had us pair off and read them to one another.  Each of us heard this list of affirmations read by another.

As is always the case with such exercises, it felt stilted and awkward and artificial (even though each of us did his or her best to read the words with some feeling).  Beyond that, I am of a certain age and a certain inclination.  So, with all due respect to the presenter, I couldn’t get out of my head the image of Stuart Smalley, the character from Saturday Night Live.

But also I did feel something.  Even in that artificial setting, the words were good to hear.  And, since I am really pretty conscious of and concerned about my sins, I do have those things in my history for which I feel some need to forgive myself, even where I have been forgiven by another or when my concern is less a misdeed and more simple failure to meet my own standards.  So, I was aware of my need for forgiveness, and hearing the affirmations did feel good.

That happens more often than we know.  I frequently speak with students or others about reflective listening.  Of course, critical to reflective listening is testing out and confirming what one has heard.  So, often when reflective listening is taught the first step is, “What I hear you saying is….”  That little piece of script also feels stilted and awkward and artificial.  As a result, many students in the helping professions resist that phrase.  Unfortunately, they end up also resisting the practice.  As the student resists saying, “What I hear you saying is…,” the student also ends up not simply repeating back, but also interpreting and answering.  The student doesn’t confirm, but instead tries to take the next step – and sometimes in fact they haven’t heard what the speaker intended, but don’t know because they haven’t confirmed.

So, the educator presses back again: “Make sure you’ve understood.  Again: ‘What I hear you saying is….’”  As artificial as it seems, the students work through the exercise; and they discover that, as artificial as it seems, the students feel better for having felt heard.

Some readers may be aware of the computer program ELIZA.  ELIZA was originally intended as a means to test how humans might interact with computers, and whether a program could be written well enough that a user might not be able to tell whether he or she was relating to the program or to a human being.

A DOCTOR script was written for ELIZA, that did a pretty good job of simulating reflective listening.  Remember, too, that this was back in the days of teletype interfaces and early CRT displays, so there was nothing like the capacity to simulate interaction that our more sophisticated programs manage today.  However, even when simply reading the words as they clattered on the printer or as they appeared on an old green monitor, and even when the user was conscious that he or she was relating to a computer, folks felt better and felt heard.  Some also attributed meaning and even feelings to the computer.  This was consistent enough, and also disturbing enough to the researcher, that he dubbed it “the ELIZA Effect,” to describe humans projecting feelings onto computer interactions.

While I’m sure some projection of the users’ own feelings was going on, I also think that there was something about reading those words and processing them in the users’ minds that was meaningful for the users.  That is, the users found it comforting and affirming to receive and think about those words, even in the artificial syntax of explicit reflective listening, and even in the artificial setting of an early computer interface.  The words were powerful enough in themselves and in the minds of the users that it didn’t matter that the users knew they were interacting with a computer program with no intelligence of its own, much less emotion.  The computer program didn’t in any sense really care, and yet the words were sufficiently powerful enough that users felt cared for – and some felt it strongly enough to project a sense of emotion onto the program.

My point is simply to reflect on the power of words for us human beings, and for the value of hearing words that clarify and comfort and affirm.  They are powerful, even if the context seems awkward and artificial.  They are meaningful, even if the words themselves seem stilted and trite.  We enjoy them, and even benefit from them, however we hear them – even in our own voices, spoken to a mirror.

Wednesday, December 01, 2010

Toward a Sacramental Vote

I don’t know about you, but I’ve been thoroughly disgusted by all the political stuff this fall.  I voted, but as the day approached, the sheer volume of political noise around me (both as a measure of quantity and of intensity) was no fun.  With each election in these United States I envy more civilized nations with distinct, and limited, campaigning seasons – and the shorter the better.

Interestingly, I had two elections to require my attention, both coincidentally in the same week.  We had in my diocese the election of our next bishop.  That election, with its relatively minute electorate, took hours longer than my civic participation.

We have complained early and often that siblings in other Anglican churches “don’t get” our processes for making decisions, whether electing bishops or changing our canons.  We vote.  That’s not to say that nothing is ever done by a small group in the background.  However, sooner or later things come out into a very public light for resolution – well, most things, anyway.

I remember well when I first really thought about voting in the church.  It wasn’t that I hadn’t always seen it, but since it was “what we do,” I hadn’t much thought about it.  However, in 1976 I went to be a Visitor at the General Convention in Minneapolis.  (Yes, at General Convention Visitor is a particular status, and if you haven’t any other reason to attend, I encourage you to go as a Visitor.)  As a part of my preparation, I read a book on the General Convention (a title that, sadly, has been lost over the years).  It described the process as we carry it out, and the structure within which we do it.  Something that stood out to me, though, was the theological reflection on why we do things by vote.

The author’s point was new to me in 1976, but would now be familiar to many of us.  Each of us participates in the life of the Spirit through baptism; and through baptism the Spirit participates in the life of each of us.  Each of us has some awareness, some insight to contribute about how the Spirit is moving and calling in each of us.  So, the more of us involved in the conversation, the better we believe we understand how the Spirit is moving and calling us as a body.  This is not to ignore or deny Scripture and Tradition.  Rather, it is to trust both that Scripture and Tradition reflect how the Spirit has moved and called us in the past, and also that it is in and through the Spirit that we understand what Scripture and Tradition are saying to us today.  It is, though, to maintain that the Spirit of Christ is alive and active in our midst, if only we will listen.  It is also to maintain that the Spirit calls each of us equally – equal at least in that the Spirit calls us each as much as the Spirit can; and that differences are matters of our preparation, our willingness, and our capacity to listen, and not of the Spirit valuing some of us more than others.

When we vote, to the extent we are intentional and prayerful we are making that action of the Spirit incarnate and sacramental.  It is incarnate because we give it substance.  It is sacramental because our intent is to make outward and visible what we feel is inward and spiritual.  Sure, voting is not a perfect system for that, and consensus (when we can seek it, much less achieve it) might seem clearer evidence of the unity of the Spirit’s purpose; but we do it as the best we can in most instances, acknowledging those differences of preparation, willingness, and capacity.  So, we don’t vote simply because it’s “the American way.”  We vote with the intent of expressing each individual’s sense of the Spirit’s leading and of seeking to be guided by the greatest number of those individual expressions.

Which leads me to wonder what it might mean to assert that same principle in voting in our civic life.  I remember a wonderful, intense conversation with a colleague, a parish priest in my diocese.  He was an economic conservative, and I was, as I continue to say, “somewhere to the left of Jesus.”  What made that conversation not only possible but meaningful was that we agreed on the ends we wanted to see.  We each wanted our society to reflect in some sense respecting the dignity of every human being and doing for others what we would want for ourselves.  Our differences were not about ends but about means; and so our conversation was respectful even as our positions were different.

I wonder what it would mean for us to bring that same sensibility to our civic voting.  Oh, I’m sure we’ve done that to some extent.  We are encouraged to vote according to “what will be good for the children,” or “for the common good” (although like many I seem to hear fewer and fewer voices with any sense that there a “common good” to talk about).  What would it suggest to step a bit beyond that and to see the act of voting in civil elections as sacramental and incarnational?  Granted, perhaps that’s not something we might bring to civil discourse; but surely we could consider that in our own thoughts and in our own circles.

To do that, though, we might need to take a stand about what are indeed appropriate ends.  We have many issues, in the church and out, for which we come back again and again to say that “reasonable persons may disagree.”  If we are to say, as I did in that conversation long ago, that reasonable persons may disagree about the means as long as we agree on the ends, then we have to say that some ends are appropriate and some are not.  More to the point, we have to say that the Spirit is calling us to some ends and not to others.

For some time now whenever I have found myself in a conversation about ours as a “Christian nation,” I have had to say that I cannot say that.  Certainly, I am aware that most of our first national leaders were Deists, and not Evangelical Christians in our contemporary mold; but that isn’t my primary complaint.  Instead, I feel that we cannot speak of the United States as a “Christian nation” unless and until we are prepared to  incorporate the standards of the latter verses of Matthew 25, the first chapters of Acts, and the first chapter of James.  To me, those are ends to stand with, even if we find ourselves arguing about the means.

It seems to me, too, that these ends – serving the widows and orphans and the least among us, and making sure that all have enough – don’t have to be described as explicitly Christian.  To act justly and to love neighbor as self are principles we learned from our Jewish forebears.  Indeed, care for the poor, a commitment to justice, and doing to and for others as we would wish for ourselves are reflected in every religion I know.  Contemporary atheist and agnostic writers are happy to assert their own arguments for these principles.

But I’m a Christian speaking to other Christians, and particularly an Episcopalian speaking to Episcopalians.  We share a common language, centered in life in Christ described in the Creeds and the Baptismal Covenant.  I feel strongly that we can say that these are appropriate goals for us.  More, I feel we can indeed consider that these are the goals to which the Spirit calls us, not only in the Church but in society at large.

So, I joined with my neighbors to vote in civil elections, and with my diocesan siblings to vote for our next bishop.  While, that’s done, other civic elections will come – for me, as soon as local elections next spring.  We won’t all agree on who to vote for, or what programs or policies to support.  However, I will pray we can agree on this: that we are called to make our vote, like the rest of our lives, sacramental, to make manifest in the world the inward call of the Spirit.  No, I don’t really expect it will work out that way.  Still, I can hope and pray.

Advent Thoughts at the Episcopal Cafe

My newest piece is up today at Episcopal Cafe.  It's a reflection on how one church year ends and another begins.  I hope you enjoy it.

And as always I encourage you to look around the Cafe.  There's always something interesting to read and to see, and opportunities to respond and share.  Look at what my colleagues there have offered, and share with us what our offerings mean to you.  We at the Cafe look forward to it.

Tuesday, November 23, 2010

For Episcopal Chaplains: Info on the 2011 Annual Meeting of AEHC

Let me share a brief note for my Episcopal chaplain colleagues.  Members of the Executive Committee of the Assembly of Episcopal Healthcare Chaplains (AEHC) are making preparations for our next Annual Meeting.  Once again this year we will meet in the context of the Annual Conference of the Association of Professional Chaplains (APC), meeting in Dallas March 24 through 27.  At this point, it appears that AEHC events will take place Friday, March 25.

Again this year AEHC will sponsor the Episcopal Breakfast on that Friday morning.  In light of changes to the APC Conference schedule, we will also incorporate the AEHC Conference Eucharist and the Annual Meeting into the Breakfast.  We will also have the AEHC Annual Banquet that Friday evening.  Our speaker will be Lee Hogan, Program coordinator for the Anglican Health Network (AHN).  He is particularly involved in the Health Microinsurance program that the AHN is piloting in Tanzania.  I have met Mr. Hogan, and have heard him speak on this subject.  His conviction about the program is contagious.  Look for more information as details are made final.

And if you’d like recent information about the Anglican Health Network, check out the website.  The October Newsletter is available there, with information about the Health Microinsurance program, and about growth of hospitals in India’s Kerala State, supported by the Church of South India.  It’s exciting reading for those of us who are interested in not only knowing about but supporting health ministries across the Communion.

Monday, November 22, 2010

Some Thoughts (Someone Else's Good Thoughts) on Interfaith Encounters

Years ago I served in a hospital where we used volunteers quite extensively.  We trained them ourselves to provide some basic introductory visits and help us identify patients who would need or want more attention from a staff chaplain.

One year an employee expressed an interest in becoming a volunteer.  He was a nurse aid working the night shift (11:00 p.m. tp 7:00 a.m.), and a minister in a small storefront church.  He offered in no small part to save us staff chaplains some relief with on call.  He could, he felt, respond himself, in that he was already in house (at least in the worst hours for us), and provide appropriate care.

That said, we quickly discovered that he wasn’t going to fit our structures.  His interest was in bringing patients to Christ, and especially in helping them see their need of Christ in the midst of a health crisis.  As such, he wasn’t really showing respect for patients in the terms of their own spiritual journies.

One night we met with him after the training session.  Being in Detroit, with the largest Muslim population in the country and also a large Jewish population, we asked how he would care for patients from those communities.  “Oh, I’m happy to care for Jewish or Muslim patients.  For the Jewish patient, I would speak of Jesus as the fulfillment of prophecy.  For the Muslim patient, I would speak of Jesus as a prophet, and also more than a prophet.”

After that, we pretty quickly determined that we couldn’t work with him as a volunteer.  We pointed out, too, that as one of the few aids working the night shift, his manager wouldn’t want him running all over the hospital providing spiritual care when that wasn’t part of his job expectations.

So, how is a Christian to approach folks of other religions, and appreciate how we might address those persons?  Well, Frederick Quinn, a colleague of mine at Episcopal CafĂ© has posted three essays on the subject, and I commend them to your attention.  They are:

I grant you that Quinn is an Episcopalian writing for Episcopalians.  However, for me and for my chaplain and clergy colleagues who are Episcopalians, this is a meaningful approach to the discussion.  For my chaplain and clergy colleagues who aren’t Episcopalians, I would suggest it is still worthwhile, at least to stimulate thought.

So, give these essays a few minutes.  Pluralism is the most common (and much argued) attitude that folks bring to interfaith relations.  Quinn’s essays can bring us back to foundations, and as his last essay suggests, see where we might yet go.

Wednesday, November 17, 2010

The New Game of the Proposed Anglican Covenant

The words are flying like a game of dodgeball on a playground. All of the players have points to score, and they do their best to combine speed and accuracy. The players twist and turn, trying to avoid being struck. When the balls do hit home, they certainly sting. None of the players really wants anyone else to walk away from the game, to take a ball and go home. At the same time, each of the players is wondering if elimination in the game will become elimination from the game, as if having to leave the field of play also means having to leave the neighborhood.

The topic is the Anglican Covenant. The occasion and the sense of urgency is the meeting of the General Synod of the Church of England, where there will be an initial vote on the Anglican Covenant as proposed. Proponents of the Covenant seem to seek in the same breath to be reassuring and convicting. Opponents seem convicted but certainly not reassured. Godwin’s Law has been cited.

Perhaps I’m too well informed, but I’ve been reading and paying attention. I think I understand several themes in the argument. Opponents say that this document creates new institutions, institutions that have authority at least for signatory churches, and perhaps within the existing Instruments of Communion. Proponents point out (with some merit) that there aren’t new institutions, and that any authority is persuasive and commendatory, and not juridical. Proponents say that the Covenant respects the autonomy and internal structures of signatory churches, and point to explicit language within the Draft. Opponents say that the commitments the Covenant seems to require undermine local constitutional structures in ways that belie the explicit language. Opponents say that the Covenant creates a coercive environment in which one province’s displeasure can stifle Spirit-led innovation, or at least make the cost such innovation excommunication. Proponents say that the Covenant provides ground rules to keep signatory churches in conversation while such differences are discussed, and so prevent excommunication, or at least forestall it as long as possible.

Yesterday, Canon Alyson Barnett-Cowan, Director for Unity Faith and Order for the Anglican Communion Office issued an interpretive comment.  That, too, has become part of the game, another ball to be thrown, another target to be thrown at. However, it did include one comment that everyone would agree to, if not to the same point. If we are to comment on the Covenant as proposed, we need to read it.

So, I went back and read it again, looking perhaps for a new way to think about it. That’s when I discovered something I found a bit confusing. It is that the Covenant doesn’t really clarify the relationship between churches of the Anglican Communion and signatory churches of the Anglican Covenant.

Now, that’s not obvious at first. After all, it is titled, “The Anglican Communion Covenant.” Moreover, in the Preamble it states that those who “solemnly covenant together in these following affirmations and commitments” come from the “Churches of the Anglican Communion.” Much of the text is dedicated to describing a common heritage among churches in the Anglican Communion. However, all that notwithstanding, the relationship between the churches of the Anglican Communion and the signatory churches remains unclear.

The thing is, the Covenant as proposed only applies to signatory churches. That’s clear, isn’t it? Churches that don’t sign on aren’t bound by the Covenant. This is clear in Section 4, considered critical enough that it survived three revisions. Certainly, the hope of those who propose it is that all the churches of the Anglican Communion will sign: as paragraph 4.1.4 states, “Every Church of the Anglican Communion, as recognised in accordance with the Constitution of the Anglican Consultative Council, is invited to enter into this Covenant according to its own constitutional procedures.” This clarifies a couple of important things. First, the proposers have decided that participation in the Anglican Communion is defined by the Constitution of the Anglican Consultative Council (ACC) – and, so, not by signing onto the Covenant. So, if the Anglican Communion is those churches recognized by the ACC, signatory churches of the Covenant are something else – churches of the Anglican Covenant.

The next paragraph goes even further in making the distinction:

(4.1.5) The Instruments of Communion may invite other Churches to adopt the Covenant using the same procedures as set out by the Anglican Consultative Council for the amendment of its schedule of membership. Adoption of this Covenant does not confer any right of recognition by, or membership of, the Instruments of Communion, which shall be decided by those Instruments themselves.

Now, this creates an even more interesting distinction. See, while some other churches may adopt the Covenant in response to an invitation to join the ACC (“procedures… for the amendment of [ACC] membership”), it’s also possible to adopt without that invitation. Under what other circumstances would adoption not “confer any right of recognition by, or membership of, the Instruments of Communion?” Adoption that includes joining the ACC would certainly confer such rights.

And, of course, “This Covenant becomes active for a Church when that Church adopts the Covenant through the procedures of its own Constitution and Canons.” So, the Covenant has no meaning, no authority for any Church that doesn’t adopt it; and even for a Church that does adopt it internally (“through the procedures of its own Constitution and Canons.”), adoption in itself does not make the Church a member of the Anglican Communion as defined by membership in the ACC.

This is confirmed by the acceptance of the reverse:

(4.3.1) Any covenanting Church may decide to withdraw from the Covenant. Although such withdrawal does not imply an automatic withdrawal from the Instruments of Communion or a repudiation of its Anglican character, it may raise a question relating to the meaning of the Covenant, and of compatibility with the principles incorporated within it, and trigger the provisions set out in section 4.2 above.

So, just as adoption of the Covenant doesn’t make a church a member Church of the Anglican Communion, withdrawal from the Covenant doesn’t in itself remove one from the Anglican Communion. It would certainly “raise a question relating to the meaning of the Covenant, and of compatibility with the principles incorporated within it,” and perhaps even “trigger the provisions set out in section 4.2 above.” But, those provisions are only applicable for those who have signed the Covenant, and not automatically to the Churches of the Communion

But, what about all those commitments made in the first three sections, commitments that are intended as meaningful consequences of accepting the characteristics of the Anglican heritage as described in those sections? While Anglicans broadly may accept them (indeed, with a few small reservations I can accept them), they are only grounds per se for agreement, or for disagreement, for those churches that sign on to the Covenant. Indeed, the commitments themselves state again and again that they are not specifically Anglican, but are “common pilgrimage with the whole Body of Christ” (1.2.8) and part of “the work of the whole people of God” (2.2.4)

So, we really do have two bodies. We have the Churches of the Anglican Communion, defined as such (at least for the Covenant) by the Constitution of the ACC; and we have this other body of those churches that are signatory to the Covenant. These two bodies are broadly overlapping but not identical. So, at least at the beginning, we have the Churches of the Anglican Communion and the Churches of the Anglican Covenant.

I grant you, it does add to the confusion that the Churches of the Anglican Covenant plan to make use of the Standing Committee of the Anglican Communion as overseer of common life and arbiter of differences. It doesn’t help that in disputes there is consultation with and deference to the Instruments of [the Anglican] Communion, even apparently for churches that have no “right of recognition by, or membership of, the Instruments of Communion.”

However, as I read this Covenant as proposed, it makes an important distinction between the Churches of the Anglican Communion and what I have called “the Churches of the Anglican Covenant.” Under the Covenant, “Churches of the Anglican Covenant” are accountable under the Covenant’s provisions to one another, and even (through respect for the Instruments) to Churches of the Anglican Communion. However, a church of the Anglican Communion (a member of ACC) is not necessarily accountable to a Church of the Covenant (whether or not that church is a member of ACC).

So, for example, we can do a thought experiment. Say that Uganda and Australia sign the Covenant and the Episcopal Church doesn’t. Say then that Uganda raises with Australia an issue regarding lay or diaconal presidency at the Eucharist. Under the Covenant Australia is accountable to Uganda. However, the Standing Committee would consult with one or more of the Instruments; and the Episcopal Church participates in three of them (Lambeth, the Primates meetings, and, critically, the ACC). So, even without signing the Covenant, the Episcopal Church would be at least influential in the recommendations to the Standing Committee, and so (at least possibly) in the recommendations of the Standing Committee to Australia – recommendations that, if not accepted, could lead to discipline of Australia under the Covenant.

I like my games analogy for understanding this, but I want to suggest different games. Bid whist is not contract bridge is not spades. All three games have similar play, but rules that are different in important ways. So, by establishing a new set of rules for those who sign on, the Covenant creates a new body and a new game – a coherent game, certainly, but not one by which players of other, earlier games are bound. There is no automatic relationship, and no automatic accountability, between a Church of the Anglican Communion and a Church of the Anglican Covenant. Canon Barnett-Cowan actually does get this. Look again at her statement,

It is also not true that non-signatories would no longer count as part of the Communion. There will be Provinces which have adopted the Covenant, and there may be (though one hopes not) Provinces which have not. They are equally members of the Anglican Communion, according to the Constitution of the Anglican Consultative Council. The difference would be that signatories will have made a commitment to live in that communion in a particularly enhanced way, and to a process of consultation and common discernment.

So, Churches of the Communion remain Churches of the Communion; and Churches of the Covenant, who may or may not be a Church of the Communion, have decided to embrace external accountability, and all the limitations that might come with it. Is this an “enhanced” way of “[living] in that communion?” Well, no, since member churches of the Covenant are not automatically members of the Anglican Communion; but also, yes, if perhaps in the sense that the penalties for differences within the Churches of the Covenant might be said to be “enhanced.”

Without doubt, and within its own terms, the Anglican Covenant as proposed creates a “new game,” refined from the terms of the “old game” as contract bridge was refined from whist. It creates less two tiers within the Communion and more two overlapping bodies, one accountable within the terms of the Communion (however few and vague they may be), and one accountable both within the terms of the Communion and of the Covenant. Somehow, I can’t imagine that bringing more clarity. Instead, it seems to me to bring less; and if it brings less clarity, then something less than “the highest degree of communion possible.” (3.2.7) And if that’s the result, I don’t see why the Episcopal Church, or any other Church, should be all that interested.

Monday, November 15, 2010

The Coming Medicare Bomb - Again

In my paper this morning was an editorial by a local physician pointing again to the issues raised by how we currently pay doctors for seeing patients under Medicare.  Here is a similar editorial in the Nashville Tennessean by a physician there.  Both point out as well that these reimbursement issues apply to Tricare, and so apply to the families of active duty service members.

Of course, receiving 25% less money for the same level of care, the same number of patients and procedures, is a problem for most doctors, who are, as private practitioners, essentially small business owners or participants.  While most are all for looking for more efficiencies and other ways to save money, that won’t be enough.  So, some doctors are deciding that they will not accept any new Medicare patients.  Of course, as our society is aging and living longer, there are more and more new Medicare patients all the time.

These doctors aren’t pointing to new discoveries.  These difficulties have been known for a while.  Yes, there was a new story in the Boston Herald this weekend; but, there was also a paper ten years ago.  In fact, I found a story in the New York Times in 1992.  That’s how far back this issue goes.

For a number of years now Congress has been acting every year for some time now to stave off the reductions in reimbursement.  They’ve prevented the problem from getting worse, but they haven’t done what needs to be done to make the problem better.  That would require reconsidering the way in which these reimbursements are set.  Unfortunately, that’s a lot harder than simply saying, “Well, we just won’t allow that change  - this year.”

It seems to me that there is a failed premise behind this.  The idea is that if Government restricts what doctors get paid, the doctors will buckle down, become more efficient, become more productive, and costs won’t rise.  Of course, other costs aren’t controlled that way.  So, the doctors have been paying more each year for everything from their supplies to their utilities.  They’ve had to pay their employees more each year.  They’ve even had to pay more each year to provide their employees with health insurance.  At some point these lines have to cross: doctors can see only so many patients, and can provide only so many services, and sooner or later they simply can’t “do more with less.”  There simply isn’t anything more to cut.  Politicians love to talk about “trimming the fat,” but sooner or later there’s no fat left to cut – and eventually damned little steak!

The doctors whose editorials I cite want folks to communicate to members of Congress.  I think that’s a good idea, even if in the current climate one could feel hopeless of actually being heard.  I think it’s a good idea to send an email or a fax, or make a phone call – or even send letter by post, despite the fact that security will slow delivery.  No, it probably won’t be fixed quickly.  But if we as citizens push steadily, it can be fixed.

Thursday, November 04, 2010

'Twas the Night Before Convention

Over the years, there is something I've said many times to students and new volunteers.  Eventually, it comes down to this: we pray for the Spirit, and trust our guts.  Barring a vision or an audition - and if it's going to come, it would be best for it to come to all of us - that may well be where many of us are for the election of the next bishop.

And after years of that approach, I remain convicted that if I'm praying faithfully, by God's grace my gut is trustworthy.

Monday, November 01, 2010

Thought for the Day Before the Midterm Elections

Remember, America: there's someone out there who doesn't want you to go vote!  Don't give that person the satisfaction!

Friday, October 29, 2010

Preparing for an Election

Now and again I am reminded of classics of literature, classics that I’m afraid too few folks know these days.  They bring us phrases and images that we have used to illuminate our speaking and writing; but without knowing the sources folks don’t really understand the images.  The Bible comes to mind, as do the works of Shakespeare. 

However, this evening I’m thinking of the fables of Aesop.  How many know they are the source of the phrase “don’t be a dog in the manger?”  That’s not related to the manger we know best – the one Jesus was born in – but to a story about a dog in comfort who prevented an ox’s dinner.  How many know the fables are the source of the phrase “sour grapes?”

Tonight, though, I’m thinking of the frogs who wanted a king.  You can read that fable here.  Go ahead – it will only take a minute or two.

Now that you’ve read it, you’ll understand the question of whether one would prefer King Log or King Stork.  Sure, King Log seems ineffective, even inert; but he won’t consume you like King Stork.  King Stork has an energetic, even aggressive program; but King Log will leave your life pretty much as he found it.

In these political times some might assume the civil government brought this to mind.  However, I’m thinking about something smaller and more singular.  Very soon now I will participate in the election of the next bishop of my diocese – the election of my bishop!  It’s not the same.  Oh, we vote, and there have been efforts to inform the voters – in this case, the diocesan convention – as well as those the voters will represent in one sense or another.  But, it’s not the same.  There aren’t campaigns, or at least nothing on the same sort of scale.  (I suppose there may have been some “campaigning,” but I’m not in the right circles to know.)  There haven’t been “campaign promises” (or, again, I’m not in the right circles).

But the most important way in which it’s different is that we’re praying to be guided by the Spirit.  We decide by voting, but we are praying that our voting will conform to God’s intent, and that instead of us deciding who our next bishop will be, the Spirit is using us to express God’s decision.

But, as I often say with patients, it would be much easier if God were better at conversation.  I have heard a voice that I thought was God, and circumstances seemed to confirm it; but I haven’t heard a voice about this Episcopal election.  Even if I had, I couldn’t be sure anyone else had heard that voice. 

So, each of us going to have to think about several questions: what do I want in a bishop?  What are the gifts and skills I think a bishop should have for the good of the diocese?  I’m not going to answer that definitively on this blog, much less in this blog post.  At the moment I’m just conscious of being betwixt and between.

How do I balance my own wishes and the good of the diocese – to the extent I’m able to separate the two?  How do I apply in the best Anglican tradition Scripture, Tradition, and Reason?  How do I decide among the candidates?  Each brings gifts and limitations, and none would be perfect; for, don’t we observe at each such election that Jesus couldn’t get elected as a bishop?  So, how do I choose among them, trying to figure out whose specific balance of gifts and limitations best fit whatever needs I focus on? 

And so, I find myself wondering whether I would be better off with King Log or King Stork.  And of course it isn’t really that straightforward, because none of the candidates is as passive as King Log, nor as destructive as King Stork (or at least we pray not).  How do I decide?  How?  How?

So, remember us in your prayers.  I’m trying to hear God, and I believe the other clergy and lay delegates are as well.  Remember us, and pray that we might hear clearly for our souls’ health, the health of the diocese, and the health of the Episcopal Church.

Friday, October 22, 2010

Reviewing the Evidence

I know I’ve complained more than once (say, here or here) about problems with how medical research is conducted and paid for. The problems I’ve occasionally pointed to are known, if not always discussed. The consequences could be quite serious. You have to wonder who’s paying attention.

One answer is John Ioannidis and those who study with him. Dr. Ioannidis of the University of Ioannina in his native Greece is a meta-researcher, a researcher whose expertise and interest is in critiquing the work of other researchers. He is profiled by David Freedman in the latest Atlantic Magazine, as one of their "Brave Thinkers," and the article is well worth reading.

Dr. Ioannidis has combined his expertise in medicine with a talent for math to look closely at what some of his peers have presented and gotten published. When he looked, he had legitimate concerns about what he found. In one review published in JAMA, the Journal of the American Medical Association, he reviewed 49 well regarded studies, 45 of which stated that they had demonstrated effective therapies. He then discovered that 34 of those 45 studies were replicated, and of those 34, 14 were either “wrong or significantly exaggerated.”

While the standard concerns about funding for research biasing the questions, and therefore the results, Dr. Ioannidis suggests another. As Freedman describes it,

Imagine, though, that five different research teams test an interesting theory that’s making the rounds, and four of the groups correctly prove the idea false, while the one less cautious group incorrectly “proves” it true through some combination of error, fluke, and clever selection of data. Guess whose findings your doctor ends up reading about in the journal, and you end up hearing about on the evening news? Researchers can sometimes win attention by refuting a prominent finding, which can help to at least raise doubts about results, but in general it is far more rewarding to add a new insight or exciting-sounding twist to existing research than to retest its basic premises—after all, simply re-proving someone else’s results is unlikely to get you published, and attempting to undermine the work of respected colleagues can have ugly professional repercussions.

We might consider this the “headline bias:” as is commonly said in the news business, “if it bleeds, it leads,” and the sensational is more likely to get attention, even apparently in peer-reviewed journals. Caught between pressure to publish on the one hand, and the general need to fit in with one’s professional peers, both researcher and reviewer can get caught up in highlighting the new and different, even if there’s better information in the replication of earlier studies, whether to affirm or refute them.

The profile of Dr. Ioannidis is an interesting article, and it highlights explicitly the importance of this meta-research. We claim early and often that we want to make our decisions based on evidence. The assumption, of course, is that the information we have is accurate and dependable – that is it, in fact, evidence. If we find it isn’t – when we find it isn’t – we need to take one of those most difficult steps in human experience: we need to take a step back and think again.

Tuesday, October 19, 2010

A (Bizarre) Window Into an Important Process

I have mentioned before that I participate in the process in my hospital of overseeing the credentialing of physicians.  That is, I’m part of a committee that looks over the shoulders (in our case, literally in the same room to watch the work) of the physicians who decide whether physicians have the training, licensure, certification, and practice history to qualify for privileges at my hospital.  It can be an interesting process, and I’m quite appreciative at how hard the physicians on the credentialing committee work and how seriously they take this.

So, it certainly caught my attention that the California Board of Medical Examiners has begun hearings before and administrative law judge on the practice of Dr. Michael Kamrava, the fertility specialist who implanted and cared for Nadya Suleman, mother of fourteen including the octuplets for which she was labeled “Octomom.”  The Board is raising the questions of whether this was in Ms. Suleman’s best interests, in the best interest of children, and in accord with the standards of care of physicians providing this specialized care.

That phrase, “standard of care,” is important in medical practice.  It carries connotations of professional standards, clinical competence, and benefit to the patient.  In any given specialty establishing the “standard of care” involves knowledge of current research, often expressed by statements from professional societies.

And there are standards of care in fertility medicine.  As a result of his practice, exemplified perhaps in his care of Ms. Suleman, Dr. Kamrava has been expelled by the American Society for Reproductive Medicine.  That does not affect his medical license, but it is a damaging critique of his practice.  By itself, his expulsion doesn’t affect his ability to maintain his practice, but it may well affect his privileges with hospitals around him.

There are certainly many issues around fertility medicine, and especially around the production of numbers of embryos to be maintained in frozen storage until – and unless – desired.  At the poles, there are those who consider them “products of conception” that can be discarded unless offered for some use, such as development of human stem cell lines for research and/or therapy; and those who, committed to the belief that these are persons held in abeyance, want to see them offered for adoption by implantation.  It raises issues of whether children are blessings and miracles of God, that for medical reasons some may never receive; or objects (even if of affection) to which we have “a right.”

However, those issues will not be at the forefront in this review.  They won’t necessarily be irrelevant, but they won’t be primary to the discussion of “standard of care.”  This review will not question premises underlying this medical specialty, but will focus on practice within it.

It is worth noting that this is a process that rarely gets this level of attention.  That is, physicians are challenged all the time, whether in court or before a state board, but it is rarely of more than local interest.  It gets into local papers, and goes into state registries, but doesn’t get national attention, or even hold the local attention for long.  There is a National Provider Data Bank maintained by the Department of Health and Human Services to which states can submit adverse actions against physicians.  The purpose of the Data Bank is

intended to improve the quality of health care by encouraging State licensing boards, hospitals, professional societies, and other health care organizations to identify and discipline those who engage in unprofessional behavior; to report medical malpractice payments; and to restrict the ability of incompetent physicians, dentists, and other health care practitioners to move from State to State without disclosure or discovery of previous medical malpractice payment and adverse action history. Adverse actions can involve licensure, clinical privileges, professional society membership, and exclusions from Medicare and Medicaid.

But, the information is really intended for hospitals and other institutions, and not the general public.  That is in its own way problematic.  It’s not unheard of for a physician to move enough so as to change jurisdictions ahead of consequences, and the public hears little about it.  This will give an opportunity for most of us to observe a review that is commonly out of sight.

Testimony has begun, and even after testimony a decision may take the California Board a while to issue a decision.  One way or another, it will be interesting to watch, and hopefully enlightening. 

Friday, October 15, 2010

Political Thought for October 15, 2010

Why is it only "class warfare" when those at the bottom make demands of those at the top, and never when those at the top make demands of those at the bottom?

Wednesday, October 13, 2010

Some Reflections on the New Atheists

They speak of matters that only they and their followers perceive.
They speak of matters both vast and infinite, and intimate and infinitesimal; but they assert that these matters directly affect our lives and our futures, as individuals and as a species.
They describe these matters in a highly technical language known well only to a small specialist caste.
They establish institutions to sustain their studies, educate their followers, and promulgate their teachings.
They gather to share their minutiae and publish their works.
They do their best to share their ideas with the public, but have difficulty getting across anything but the broadest ideas, which almost always get distorted.
Some of them are determined, and even militant, about defending the truth of their understanding of the nature of things against other understandings.

Who might I be talking about? How about, for example, Richard Dawkins and Stephen Hawking? I’m talking about the material determinists preaching (yes, preaching) under the heading of the “new atheists.”

Lets’ try this again.

They speak of matters that only they and their followers perceive.
  • Have you ever actually seen a quark, much less been able to tell which is top or bottom, which is charm or strange?

They speak of matters both vast and infinite, and intimate and infinitesimal; but they assert that these matters directly affect our lives and our futures, as individuals and as a species.
  • For example, quantum mechanics and astrophysics; or genes and ecosystems.

They describe these matters in a highly technical language known well only to a small specialist caste.
  • Specifically, higher mathematics. It is the language – indeed, for much of their work the only language – in which these concepts can be described with precision.

They establish institutions to sustain their studies, educate their followers, and promulgate their teachings.
  • How about MIT or Cal Poly; or, for that matter, the departments of Physics, Astronomy, or Engineering of any major university.

They gather to share their minutiae and publish their works.

They do their best to share their ideas with the public, but have difficulty getting across anything but the broadest ideas, which almost always get distorted.
  • Think about reports of scientific discoveries in the public press, especially in the areas of nuclear research or medicine.

Some of them are determined, and even militant, about defending the truth of their understanding of the nature of things against other understandings.
  • Again, think of Richard Dawkins, or Victor Stenger.

They speak with certainty, or at least with conviction, of matters which are based in fact on assumptions.
  • This takes a bit more reflection, but it’s clear. Take, for example, the pursuit of a Grand Unified Field Theory. The idea has long prevailed that there must be one theory (in fact, one equation) that will account for electromagnetism, gravity, and the strong and weak forces within the atom; and indeed that the theory must be elegantly simple. That idea is an assumption. It can be argued for and against, but it’s an article of faith.
  • Or, again, take quarks. No one has seen one. They are predicted in the math, and in the results of high energy physics experiments at CERN and elsewhere spots and lines show up in the film that seem to match the math; but the math is part of a specific model, a mathematical construct. Suppose one of the premises of the model is wrong.

Now, let me first acknowledge that this also applies to religion, right down the line. In fact the language of theology, at least of academic theology, is awfully technical and obscure. That’s part of the reason that in fact stories of religion in the public press are so dependably partial.

Second, I’m happy to acknowledge that the scientific community is in fact quite diverse. I have observed before that I grew up surrounded by folks with PhD’s in the hard sciences, including my father, who were also active in faith communities. Folks like Dawkins and Stenger are extremists to the point of becoming stereotypes, and not really representative. (And I’ll admit I’m not sure about Hawking and Christopher Hitchins. Hawking spoke of God as “unnecessary,” but I haven’t heard much anti-religious commentary from him. Hitchins is a journalist and not a scientist per se; and while he’s clear on his position, lately he’s been much less, well, obnoxious in his rhetoric. And I respect his recent statements that his diagnosis of cancer will not change his beliefs.)

But, only the extremists in the religious traditions deny that these are matters of faith, and not provable. By the same token, its the extremists among the material determinists who deny their underlying assumptions and feel they must be militant about the exclusive reality of their world view.

This has gotten a lot of ink and pixels lately, including among some of my colleagues. To some extent, I think that’s because, whether we realize it or not, they are behaving just like us. What I think is interesting and ironic is realize that they are behaving just like us; and they’re absolutely blind to it.

Monday, October 11, 2010

Opportunities to Hear From Military Chaplains

I received an interesting email from Marcia Colgar, owner of the website She has a blog on her website, and she wanted to inform me of her post, Top 25 Chaplain Bloggers. And I do find it interesting. All of these bloggers are military chaplains; and while I have spent my career in health care chaplaincy, I have great respect for my colleagues in military chaplaincy. I did also note that right now one of them is in health care chaplaincy. Specifically, he’s just begun a CPE Residency in a military hospital.

I am not making comments pro or con regarding online education. I’ve known graduates from Ivy League schools who appeared to have come away with all the right connections, and virtually nothing else of value; and I’ve known folks who really had learned an awful lot simply in being well read. I will say that the blog is interesting, including in addition to the list of military chaplain blogs, the (very respectful!) post 50 Best Blogs for Wiccans. So, take a look at least at the Top 25 Chaplain Bloggers, and remember the important ministries of our colleagues in military chaplaincy.

Monday, October 04, 2010

"Evidence-based" Needs Good Evidence

I’ve written before about evidence-based medicine.  As a general principle, I believe in it.  I certainly think we ought to be reviewing, studying, and evaluating our health care interventions and discarding those that don’t work or, worse, actually do harm.

So, I was certainly interested when my Best Beloved directed me to Huffington Post and this article by Mark Hyman, MD.  Dr. Hyman lays out serious problems with some of the evidence on which our recent medicine has been based.  And he’s not simply expressing an individual opinion, however informed.  Instead, he points to recent reviews of research in JAMA, the Journal of the American Medical Association; the Archives of Internal Medicine; and the New England Journal of Medicine.  So, there’s evidence that the evidence has been distorted on which some important medicine has been based.

Much of this has long been a concern.  Research has been directed by those pay for it.  Now, it can be a small issue in choosing the direction of research.  People choose to research what funders will pay for.  One result is that practical, potentially profitable research gets funded, and basic research – fundamental research that may stimulate something potentially profitable, or may not - doesn’t.

It’s a much more serious issue when the interests of the funders drive the results of the research, or the way the results are reported.  There has long been a complaint that when pharmaceutical research shows a study drug doesn’t work, or doesn’t work better than competitor drugs, the results don’t get reported, or get distorted.  Now there are reviews like those Dr. Hyman points to that say document instances of this.

And then there are the issues of drugs sold and prescribed “off market” – that is, to treat conditions for which the drugs haven’t been tested.  Granted, sometimes those “off market” applications can appear to offer benefit; but that benefit hasn’t been documented, or documented well, and the risks specific to the “off market” use haven’t been determined.  That’s why it’s illegal for pharmaceutical companies to market drugs for the “off market” use.  Unfortunately, as Dr. Hyman documents, the costs of those violations in terms of fines are nothing compared to the profits.

I will also note that Dr. Hyman shares my feelings about reports of research in the news media.  He notes that often reporters focus on headlines that misrepresent the study results, or amplify a study’s importance all out of proportion.  If on top of that the research has been badly done, and/or the reports in the peer-reviewed sources are distorted, it becomes not only more difficult but perhaps outright hazardous to trust a news report on any given study.

Dr. Hyman has seven steps we can take, and I think they bear repeating.

How to Protect Yourself From the Spin Doctors

1. Follow the money: Be a detective and look up the articles mentioned in the news. Find the study, see who wrote it, and determine what financial conflicts of interest they have. Also check who funded the research.

2. Do your homework: Be suspicious of media reports of scientific findings. Does the finding make sense in the context of other studies and is it the best possible approach. Educate yourself by learning to use PUBMED (the National Library of Medicine) and reviewing different perspectives.

3. Does it pass the "sniff test": Is the treatment suggested just a "me too" drug that has not been proven to be any better than existing treatments? Does it make sense to you or does something smell rotten? Trust your intuition.

4. Advocate for an arm's length relationship between industry and academia. Write your Senators and Congressmen to develop new regulations and legislation that will build a fire-wall to protect us. Grants are fine, but Pharma should have no participation in study design and should not be allowed to interpret or publish results.

5. Demand a no revolving door policy between industry and government regulators. Former drug company executives should not be on FDA committees or involved in regulation or legislation.

6. Advocate for comparative effectiveness research. Preventing this research allows Pharma not to play fair.

7. Campaign for finance reform: If done effectively, can limit the influence of industry on government.

I think these are all steps well worth taking as individuals, and worth requiring of both those who provide our health care and those who pay for it.

So, take the time to read Dr. Hyman’s article.  It will give you pause.  But, if we can press researchers, health care practitioners, payers, and community leaders to change, work like his can also give us all better health care.

Sunday, September 26, 2010

Unrest at Episcopal Cafe

Or, more accurately "unrest-cure."  My newest piece is up at Episcopal Cafe, and my "unrest-cure" is my starting point.  So, wander over to the Cafe and take a look.

And while you're there, check out what my colleagues have written there.  My colleagues are always interesting, and we contributors are always interested in comments.  Catch some news, read some great essays, and explore the multimedia presentations, and then let us know what you think.

Thursday, September 23, 2010

Thought for 9.23.10

Do not answer fools according to their folly, 
   or you will be a fool yourself. 
Answer fools according to their folly,
   or they will be wise in their own eyes. (Proverbs 26:4-5)

 This is one of my favorite passages of Scripture, and one that I wrestle with frequently.  How important is the issue at hand?  Just how far off is the person I'm addressing?  Just how certain am I of my position (okay, well, that isn't an issue all that often)?  Sometimes I wonder if I don't need in more cases not to answer the fools.

But if we all did that, whatever would happen to the blogosphere?

Wednesday, September 22, 2010

Another New Resource on Bioethics

Yes, I've been away a while.  I'm back, and I have some stuff in process.

In the meantime, I want to point to a new ethics resource.  I've written before about the Center for Practical Bioethics.  They have some good resources on their web site, and have for some time have the blog Practical Bioethics and the Practical Bioethics Media Center.  (For more, check out the Center's page under "Center Media" in the right sidebar.)

Well, the folks at the Center have been busy.  They're now involved in the American Journal of Bioethics (AJOB) and its web site,  You can access there the content of AJOB, and also a blog discussing these issues.

So, when you're checking into research and writing on bioethics, this is another worthwhile site.  Take some time to see there what's of interest to you.

Wednesday, September 01, 2010

An Opportunity

I don't often recommend a service, but here's one for all my chaplain geek colleagues - that is, for the really determined research-informed chaplains.  SAGE Publications offers a wide selection of professional journals, including many from outside the United States.  I first discovered them when accessing journals through my health system's library, but then was able to access them from home.  Many of them they make available on the web.

Now and again SAGE Journals Online offer free access to their entire list.  I'm sure they hope that readers will discover journals to which they want to subscribe.  In any case, periodically they offer an opportunity to sign up for free access, usually for a period of four to six weeks.  For those of us who find browsing new journals to be voyages of intellectual discovery, it's a lot of fun.  For example, a search on the word "chaplain" produces more than 2800 citations.

And they're offering it now.  So, link over and think about whether you want to register.  You might find a lot to see.

Tuesday, August 31, 2010

Looking Again at the Anglican Health Network

Once again the Council of Anglican Provinces in Africa (CAPA) has met.  There have been the predictable comments rejecting the Episcopal Church.  However, during the buildup to the conference many comments were repeated about Uganda specifically not accepting financial assistance from the Episcopal Church or sources within the Episcopal Church – even as some were noting support for the conference from Trinity Episcopal Church, Wall Street.  Logistical support form Trinity notwithstanding, it was because of decisions like Uganda’s that caused me concern about loss of support for joint ministries.

Which brings me to the Anglican Health Network.

It’s been a while since I mentioned the Anglican Health Network here “at the Bedside,” as it were.  In that time, a lot has happened, and it’s worth sharing.  Here are some highlights you can find at the Network’s web site:

  • There’s the Health Microinsurance Project, now being piloted in Dar es Salaam, Tanzania, and in Karakonam, India.  The idea is to apply the same principles to health insurance that have been so effective and so important in providing microcredit, small business loans in developing countries.  The Network has brought together individuals and dioceses that can provide some seed money, but the intent is that this will become self-sustaining.  It will allow thousands to take advantage of medical care that is already around them but beyond their financial reach.  In fact, the India project has already registered 25,000 members.
  • You can access the Newsletters of the Anglican Health Network.  This summer’s Newsletter has articles on malaria, with a sidebar on the Nets for Life Program; on health issues at the G20 Summit; and health ministries in Haiti.
  • There are links to Anglican and Episcopal hospitals and health ministries around the Communion.
  • There’s even a blog with periodic posts by Paul Holley, Coordinator of the Network.

The Network grew from ideas shared at the first International Episcopal/Anglican Healthcare Ministries Conference in Houston, Texas, in January, 2009.  Individuals and institutions in the Episcopal Church are involved, and have been involved from the beginning.  However, the Network has taken off with some important programs.  We have a lot more going on in health ministries in the Anglican Communion than most of us know.  The Anglican Health Network web site is a good place to start learning about it.

Monday, August 23, 2010

Up Again at Episcopal Cafe

My newest piece for the Episcopal Cafe has been posted.  It's a reaction to "the new Carnegies."  It's a reflection both current and historical, I think; so take a look, and let me know what you think (there or here).

I'm raising a question: what ever became of investing in human resources - a question that goes way beyond simply adding jobs and employing people.  Investing in human resources involves good public education (K through whenever); good public health (because all our health is public); and, an economic that, while not preventing some of the rich from getting richer, at least strives to prevent the poor from becoming poorer.  Sure, there are good employers that do invest in their people; but really investing in human resources as a society will take a whole lot more than that.

Friday, August 20, 2010

For the Public Good - Before the Bugs Win

We've been talking a long time about antibiotics.  We've talked about overuse because of an expectation that the doctor will "do something," especially for children.  We've talked about drug-resistant strains of disease-causing bacteria.  We've talked about patients not completing an antibiotic prescription, allowing resistant bacteria to survive and multiply.  We've talked about those drug-resistant bacteria moving from the hospital into the community.  We've talked about antibiotics in agriculture, and how they might affect us as they end up in the food supply.  We've even talked about, or at least heard about, antibiotics ending up in the water supply, both from agriculture and from "old" pills flushed down the sink.

We've also talked about what to do when they begin to fail.  Note that I said "when," not if.  We know that, in the face of the trends above, our antibiotics will become less and less effective until, at least for some uses, they cease to work at all.  In fact, it's already happening.

A recent article in the Chicago Tribune highlights that failure, it's high cost, and key difficulties in addressing the problem.  The article focuses especially on the tension between the FDA and the pharmceutical companies.

The article focuses on one specific issue in the development of antibiotics: how, or really, against what standard should they be tested.  Is it enough for the new antibiotic to be roughly as good as an existing antibiotic for the same disease?  After all, “roughly as good” may well mean “not quite as good,” but without enough data to be certain – certain whether it’s as good, and if not quite as good, by how much.

Or, do you test that it’s at least as good and perhaps better than an antibiotic currently in use?  The two ways to accomplish that would be a double blinded comparison study, or a double blinded placebo control study.  The blinding (“double blinded” means neither doctor or patient knows which pill the patient receives) would mean that the results would be dependable.  These would set higher standards that would prove (or disprove) clear effectiveness and even superiority. 

There are, of course, two issues with the more rigorous testing.  The first is that , even testing with sinus infections and other non-life-threatening bacterial infections, how many patients would consent to a comparison trial, much less a placebo controlled trial?  The second is, of course, that the more rigorous testing takes more time and costs more money.

We need to take seriously the second issue.  According to the article, “Drug companies are abandoning the antibacterial business, citing high development costs, low return on investment and, increasingly, a nearly decade-long stalemate with the Food and Drug Administration over how to bring new antibiotics to market.”  While the article is focused on the issue of the FDA approval process, development costs and low return are significant challenges.  This is part of the challenge of for-profit health care – and pharmaceutical companies are certainly for-profit health care.  I’ve commented before that the drug companies are especially interested in medicines for chronic diseases.  Patients take such drugs regularly for years, providing a steady revenue stream.  Antibiotics aren’t quite as low return as vaccines, that, if things go right, are taken only once or a few times in a lifetime.  However, they aren’t like the chronic meds.  The patient will take them for a ten days, or a week, or less.  Indeed, in some infections the patient still receives the drug just once, as many of us received one injection of penicillin (my memory is of one painful injection, but I was small) for strep throat.

At the same time, the development costs are as high as with any other medication.  The axiom is that “The first pill costs a million dollars.  Every pill after that costs 35 cents.”  (And that axiom has been around for a while; a million dollars is, by today’s standards, blessedly cheap.)

Still, I find myself wondering if there isn’t reason to temper the requirement for profit, especially for antibiotics.  You see, pharmaceutical companies spend their time and money on applied research.  That is, they put most of their efforts into taking the research of others, and developing specific applications.  Certainly, they do some basic research – gathering new knowledge without a specific application in mind – but most basic research is done in academic and clinical settings.  Basic research is, for example, the Ph.D. candidate wandering through the jungle collecting plant samples, analyzing back in the lab the proteins and chemicals they produce, and testing what effects those proteins and chemicals might have.  Applied research is taking one of those chemicals because of an effect it has shown, developing that into a specific drug, and completing the tests that show whether it’s safe and effective.

The thing is that, while pharmaceutical companies do pay a lot to complete the applied research, they don’t pay nearly as much for the basic research they base the applied research on.  Instead, we pay a lot for it.  That is, much of it is paid for with tax revenues and fees paid to government and distributed through such agencies as the National Institutes of Health.  Much of it is also paid for with charitable contributions, whether large contributions from private foundations or smaller, individual contributions to the latest telethon.  The research is available to the pharmaceutical companies because it’s publicly available, published in peer-reviewed journals.  Sometimes it makes it possible for researchers to start their own companies, taking their own basic research and developing the applications. 

My question is what the for-profit pharmaceutical companies owe to the larger society in compensation for the basic research that they don’t pay for.  Oh, they certainly do pay taxes and contribute to charities; but, then, so do we, and I bet they don’t pay anywhere near the percentages of their income that most of us do.  On top of that, while they take some clear risks in applied research, they don’t have nearly the risk that we do paying for basic research.  Sure, some applications don’t work out, but they don’t make the effort without some likelihood of success.  Basic research, on the other hand, is knowledge for its own sake, whether there’s money in it or not.  So, arguably it’s mostly risk.  That is, while a plant sample or a new animal may produce lots of chemicals, there’s no reason to expect that any one of them, or even most of them, will be useful, or, at any rate, more useful than chemicals already identified. 

So, might we expect pharmaceutical companies to take on less profitable pursuits like antibiotics as public goods, doing so as compensation for the basic research that they didn’t pay for, but without which they wouldn’t have any products?  Somehow, I don’t expect it.  However, I think it’s a question worth asking.