Wednesday, January 27, 2010

Donation Difficulties in San Luis Obispo: the End of the Story

Two and a half years ago, concerns were raised in the field of organ transplantation. A respected transplant surgeon was accused of serious misconduct. Specifically, he was alleged to have given excessive doses of morphine to a dying patient who might have been a donor in donation after cardiac death. As a result, the physician was charged with three crimes: dependent adult abuse, administering a harmful substance, and prescribing a controlled substance without a legitimate medical purpose. A judge dismissed the latter two charges, but the charge of dependent adult abuse went to trial. I wrote about the case at the time here and here.

In my second post on this case, I noted the difficulties involved with allegations about “excessive” doses of drugs. In this case, the patient was not “narcotic naïve;” that is, the patient had a history with these drugs, a history that allowed his body to develop a tolerance, and so require significantly higher doses than would be appropriate in a healthy patient, or in a patient without that tolerance.

Now we’ve heard the results of that case. On NBC’s Dateline this past Sunday night there was a detailed report.  You can find that here, and while there is a transcript, I encourage you to watch the story. The physician was acquitted, in no small part because the Prosecution brought a poor case with poor evidence. Especially important was the failures of the Prosecution to produce either critical portions of the chart, or the nurse who would have been responsible for them.

I complain often enough about medical journalism. In so many cases reporters go for the sensational at the expense of the informative. I was frankly concerned when I saw this report announced that the same thing would happen with this story. However, to give credit where due, Keith Morrison and NBC have done justice to this story. They have certainly acknowledged the sensational aspects of this story, and how sensationalism at the time really served no one. More to the point, they have provided accurate information about this surgeon, and about donation after cardiac death.

So, take the time to read or, better, to watch this report. Sure, it’s got some of that television tension; but it’s also got the facts.

Tuesday, January 26, 2010

A Model of Being a Research Informed Chaplain

I have commented before on the concept of being a “research informed chaplain.” I based that reflection on a comment from George Fitchett, who epitomizes that effort. Well, now George has published a review of a new research article at PlainViews. If you’re not already regularly checking out PlainViews, this is a good time and reason to start.

George has reviewed an article coming out of a large, multi-center cancer study. That article should be of interest, as he demonstrates, because it suggests that interventions by chaplains have demonstrable and measurable benefits for patients in the study – something that we’ve been pursuing for some time. At the same time, George models reading the article critically, noting its strengths and limitations, and especially how those limitations affect its real usefulness for chaplains.

So, take the time to read George’s piece at PlainViews. And while you’re there, check out the other articles on the site, both current and in the Archives. PlainViews is a valuable resource for chaplains who want to keep current, and to be not only research informed, but professionally informed.

Saturday, January 23, 2010

The Midweek Eucharist: Reflections on Epiphany 3 plus

Preached at the January Kansas City Eucharist of the Worker Sisters of the Holy Spirit/Worker Brothers of the Holy Spirit, Saturday, January 23, 2010.

Welcome to the midweek Eucharist!

Oh, you didn’t know it was a midweek Eucharist? You thought that gathering on Saturday and using Sunday’s lessons that this was a weekend?

Actually, it’s the middle of the week. Specifically, it’s the middle of the Week of Prayer for Christian Unity. It began with the Confession of Peter this past Monday; and it will end with the Conversion of Paul this coming Monday; and so today, and this Sunday’s lessons, come in the middle of that week.

And I think that’s really very appropriate. Consider: on the Confession of Peter we remember that, when Jesus asked, “Who do you think I am,” Peter answered, “You are the Messiah. You are the Son of the Living God.” Jesus answered, “You didn’t think that up yourself, Peter. It had to have been revealed to you.” And considering what a block head Peter is until after the Resurrection, I can see why he said that.

“You are the Messiah,” Peter said; but, what did that mean?

And on the Conversion of Paul we recall Paul’s encounter on the Damascus Road. Now, Paul had faith. He would later say he was convicted in his faith, and a member of the Pharisee party. So, we know he had some sense of the Messiah; but he didn’t know Jesus was the Messiah. That is, until Jesus knocked him off his donkey and onto his…. Well, anyway.

So, Paul was converted to faith in Jesus as the Messiah; but what did that mean?

The Gospel for this Sunday, the Third Sunday of Epiphany, provides us with the answer. Jesus attended the synagogue, and read from the Book of Isaiah: “The Spirit of the Lord is upon me, because he has anointed me to bring good news to the poor. He has sent me to proclaim release to the captives and recovery of sight to the blind, to let the oppressed go free, to proclaim the year of the Lord’s favor.” Then he said to the congregation, “Today this scripture has been fulfilled in your hearing.” This is what it means for Jesus to be the Messiah: freedom for those in bondage and healing for those who suffer and the time of God’s grace, which is good news to all those who are in any sense poor. This is what it means that Jesus it Messiah. This is what Peter confessed, and to what Paul was converted.

This is the ministry, too, to which we are called and for which we are empowered by the Spirit. This group, named for the Holy Spirit, should certainly understand about the gifts. There is a variety of gifts, but only one Spirit. But those varied gifts aren’t simply matters of individual honor. After all, as Paul tells us, if one is honored all of us are honored; and if one is disgraced, all of us are disgraced. No, the gifts of the Spirit aren’t marks of honor: they’re operational. They’re tools that we are given to take our part in the ministry of the Messiah as Jesus proclaimed it in Nazareth.

Now, this can be difficult for us. If we stand like Peter and confess, “You are the Christ,” it calls us to commitment. If we are converted – again and again - like Paul, it calls us to commitment. To carry out the ministry requires commitment.

The thing is, we live in a culture that has a problem with commitment. We know it’s true. It’s the stuff of so many date movies! But, really, we know it in our society. Think of all the folks who don’t support universal access to health care. “I’m doing fine. Don’t call me to any commitment to anybody else.” So much of our political life these days seems to be about individuals who aren’t comfortable making a commitment to our society.

We, however, are called to make a commitment. We are here because we follow in the tradition of Peter’s confession and Paul’s conversion. That’s literally true. Peter made his proclamation in Jerusalem, and then Paul took his to the rest of the world; and both ended up in Rome. We might have our differences with the Roman Church, but we are Western Christians. Our roots still go back to Rome, the where the Church was shaped by Peter and Paul.

And we are called to commit to the ministry Jesus claimed and proclaimed in Nazareth. We are called to commit, and given the gifts of the Spirit so that we might carry out that commitment.

So, here we are, looking at the Third Sunday of Epiphany, between the Confession of Peter and the Conversion of Paul. As we confess with Peter that Jesus is Messiah; as we are converted with Paul, and converted again, to recognize that Jesus is Messiah: we are called to commit. In this week especially we are called to commit to Jesus as Messiah, and to our participation in his messianic ministry.

Welcome to the midweek Eucharist!

Wednesday, January 20, 2010

Please Dr. Gupta, I Don't Want to Go, Part 2

Let me continue my reflections on the book Cheating Death by Dr. Sanjay Gupta.

I have written on my concerns about Cheating Death as medical journalism.  In addition to those concerns, there are other issues raised by this book.

Specifically, there are ethical issues to address.  Some of these are raised and acknowledged by Dr. Gupta himself.  Another is related to issues he raises, and to the shortcomings once again of medical journalism.

Late in the book Dr. Gupta raises the issues inherent in doing research in resuscitation, including but not limited to CPR.  One could almost say that there is no ethical way to do the normal sorts of medical research with relations to CPR (almost, but not quite).  That is because we do CPR for therapeutic reasons.  We do CPR to save lives, and so the ethics of care guide our decisions.  That means, among other things, that we don’t withhold care or treatment, nor do we in general choose unproven techniques.  Of course, those are precisely what we do in much of our research.  We might withhold therapy to show that a new treatment is better than no treatment; or we might choose an experimental therapy to compare to a proven therapy.  The thing is, the greater the risk to the patient either of injury or failure, the less likely we are to take risks.  And when we’re doing CPR it’s because the risks to the patient are as high as they get.  So, it can be very hard to do research on resuscitation.

It’s not impossible.  Before my current position, I served for several years in a major medical center where we did research on CPR.  In fact I served in the Institutional Review Board (IRB) for Human Subjects Research.  My role was to address issues of ethics and patient rights, and we worked long and hard to find ways that we could do CPR research, making small, incremental changes to our standard of care over time (and early on the physicians involved were inclined to think I was opposed to research, which was far from true).  There are also, of course, retrospective studies, looking at what happened with individual patients after the fact.  However, retrospective studies can only tell us so much, and to change standard of care sooner or later we have to try (and study) something new.

So, for Dr. Gupta, whose book is about new and not yet accepted therapies for patients in extreme circumstances, is acutely aware of the difficulties of research.  And on this issue, I think he has a point.  These new therapies show promise, but the only way for them to move from “promising” to “accepted” to “standard of care” is for physicians to use them, and report on the consequences of their use – which is to say, to do research.  I don’t think that Dr. Gupta would really want us to be hasty in bringing new procedures or new medications to practice.  At the same time, I acknowledge and appreciate his concerns, not to say frustrations, with the difficulties involved in making progress in care in extreme circumstances.

Another issue raised in the book is more basic: what do we mean by “death?”  Now, this is something of a soapbox for me, if not a hobby horse (look it up).  I keep returning to the point that, as I say often enough, “Dead means that you don’t come back.”  However, the book does note that this is something of an issue in health care.  That is, as we find new techniques that help more folks survive at the end of life (or, as the book also notes, at the very beginning), we change the criteria by which we identify a patient as “dying.” 

It’s worth noting that in the book Dr. Gupta is a bit vague on the definition of death.  At the blog GeriPals, Eric Widera notes what he calls the book’s “biggest flaw – the complete lack of consistency when using the term ‘death’.”  However, I think I can say that he is consistent that in all his concerns, whether discussing “death” or why we might question the value of the diagnosis of “persistent vegetative state,” are with neurologic death.  Even his chapter focused on cancer care addresses a primary tumor of the brain.  While various chapters focus on various medical diagnoses leading to death, the death they lead to is neurologic death, whether brain death or unrecoverable brain injury.

There’s a logic to this, of course.  For a variety of reasons, brain death has been an important legal concept.  It reflects an understanding that life is about personhood, identified in personality, and not just biologic function.  Even without support, in the right circumstances heart rate and breathing can go on for some time with only the limited functions of the brain stem; and with nutrition and fluids, for quite a long time.  However, without the functions of the frontal and midbrains we do not show any personality – no interaction, no choosing, not emotions.  And if there’s no personality expressed, and no expectation that the injury can be healed, why not understand that the person is dead?

And we’ve built a number of other moral decisions on that concept.  Our understandings of “death with dignity,” and of families using substituted judgement to withdraw life support, are premised on the idea that death is about personhood and personality, and so once that it gone it’s also appropriate to forego therapies that will sustain pulse and respiration.  In most cases our practices of organ donation depend on it (notwithstanding living donors of kidneys and even of portions of livers).  Without the legal concept of brain death, these practices go by the board.

This is not to say that we shouldn’t be using new tools to learn more about injured brains.  The functional MRI studies that suggest some patients in comas are more aware and responsive than we have previously known may well help future patients we can’t help now.

However, coma is not brain death.  “Dead” continues to mean you don’t come back, whether because your brain won’t function, or because your other organs won’t.

And that distinction is also important.  While we might focus these days on neurologic death, the brain isn’t the only organ we can’t survive without.  Loss of heart or lungs will certainly cause death, but so will loss of liver or pancreas.  Like neurologic injuries, we can treat injuries to those other organs; but ultimately we can’t live without any of them, and without any one of them we will die.

So, the book raises an important issue (recognized by Sanjay Gupta the physician as well) in changes in our understandings of dying (and, for that matter, living).  However, it doesn’t really change the fact that we die.  Gupta has written about “cheating death,” but even he knows that this means using new and better techniques to delay death, and helping patients recover whom we could not help before.  We can find better ways to do CPR, and discover more going on than we knew in injured brains.  What we can’t do is really cheat death.  The mortality rate of the human condition is 100%.  For all the unexpected recoveries we celebrate, sooner or later we will all be dead; and dead means you don’t come back.

News on Endorsement for Episcopal Chaplains

Let me take a few moments to speak to Episcopal Healthcare Chaplains and those who are exploring that ministry and that call. I know that folks find their ways to this blog because of that interest. I’ve written about that in a longer post, but there have been some procedural changes worth note.

For some time, the process of ecclesiastical endorsement, required by our various professional certifying organizations, has been overseen within the Office of the Bishop Suffragan of Chaplaincies (now the Office of the Bishop Suffragan of Federal Chaplaincies) in the Episcopal Church Center (815). However, there’s been an extensive process of reorganization at 815, still in process, and it will affect somewhat procedures for endorsement.

Endorsement in the Episcopal Church continues to be a process involving both the Episcopal Church Center and diocesan bishops. The Bishop of Chaplaincies or his representative would contact the appropriate diocesan bishop to ask that bishop to endorse the chaplain. If so, then that Office would become the “office of record,” and would communicate that endorsement to the applicant, and to the appropriate certifying body or bodies. However, the Office has been focused once again on Federal chaplaincies (military, Veterans Administration, Federal Corrections, and Federal law enforcement), and with that in mind has been moved to the Washington office of the Church. Bishop Packard will be retiring this year, and his successor will have this new, narrowed focus. (For those of us who have worked with Bishop Packard and his predecessors, this does feel like something of a loss; but with so many in the military in active duty and harms way, it makes good sense to me personally.)

All chaplaincy ministries are now under the broader jurisdiction of the Office of Ministry Development. In one sense, that doesn’t mean a great change in endorsement. The same office staff at 815 will process endorsement applications. Someone at 815 will still be calling diocesan bishops to ask about endorsement, and communicating the results appropriately. However, some of transition is still in process. The Application for Endorsement is still posted at the Office of the Bishop Suffragan for Federal Chaplaincies, while waiting to be moved and linked from new Ministry Development web pages. We’re also waiting to learn which staff person at 815 will relate to healthcare chaplains and the various professional organizations.

So in the meantime, if you’re pursuing endorsement or need your endorsement renewed, link to the Application page. In addition to the form itself, it also has contact information that will help if you have questions about the current process.

And for those of you who aren’t pursuing certification and are curious about whether you should seek endorsement, you can read my reasons that you should.

Sunday, January 17, 2010

A Little Something at Episcopal Cafe

My newest piece us up at Episcopal Cafe.  It's a reflection on the season of Epiphany.  You know the old saying, "Don't sweat the small stuff; and it's all small stuff?"  I think sometimes it's precisely the small stuff most worthy of our attention.

So, go check it out at Episcopal Cafe, and feel free to leave a comment (easier now that TypeKey offers several different options for signing in).  And while you're there, check out the news and notes of my colleagues.  I think you'll find a lot there that's worth your attention.

Thursday, January 14, 2010

Please, Dr. Gupta, I Don’t Want to Go, Part 1

(With apologies and gratitude to the music of Ray Stevens.)

I have certainly written before about my concerns when research studies get reported, and often misunderstood, by the popular press. I suppose I shouldn’t be surprised that the reporter is interested in getting a good story. But that’s precisely the problem. The reporter gets so excited about the good story that he or she fails to recognize, much less convey, the limitations of the story he or she wants to tell. Unfortunately, those limitations are important. Like adding all those disclaimers in a television pharmacy ad, appreciating the limitations of studies that get reported are really in the best interest of the reading public. However, they aren’t nearly as much fun as the good story.

Which brings me to Dr. Sanjay Gupta. I’ve been reading his book, Cheating Death, and I’m afraid that I’m left with the same impression: that Dr. Gupta the reporter has overcome Dr. Gupta the physician in his effort to tell the story.

I’m not suggesting this is easy. Indeed, I think a central aspect of the book highlights the difficulty of providing information on research in the public sphere. The book is certainly readable. However, in the interest of being readable the book centers on the stories of individuals. These individuals are exceptional, usually in more ways than one. At the most important level, they are exceptions because they have survived in circumstances when almost no one would have predicted it. In addition to that (and I think related to that), most of them were in good health before the event that made their stories interesting.

As I suggested, that makes for good writing and good journalism. However, it’s not really all that good as reporting about health care. Each case serves to illustrate an area of research in health care at the extremes that Dr. Gupta finds worthwhile, but each is an individual case. That is, each of them is, in the language of research, anecdotal evidence. They are meant to be illustrative and even significant of the new procedures under discussion; but in research terms it takes more than one case to be significant. Over and above the number of his examples who were in other excellent health, and so good risks, we have no way of knowing other ways in which these cases were exceptional, more likely to survive than others in the same conditions. Anecdotal evidence is interesting, but it’s not necessarily significant. But once you’ve published in the book, how clear will that be to the reading public?

Now, to address that issue the book is extensively footnoted. That could give one a good sense of reliability. However, when I read the footnotes, I had questions. Certainly, Dr. Gupta quotes valid resources, including both peer reviewed publications and conversations with the professionals involved. At the same time, a fair number of the citations are simple of other news reports. That offers some confirmation that these events really happened, but no additional assurance that these events are really meaningful.

And even the peer reviewed publications weren’t always as confirming as Dr. Gupta thought. Part of what got me into the book was its first chapter. That chapter is devoted to therapeutic hypothermia, a treatment I’ve written about before. A major part of the chapter is a historical review of efforts to establish therapeutic hypothermia as the standard of care for patients who’ve had a heart attack. He speaks of the enthusiasm of the proponents, and of the questions of the opponents, and especially about difficulties with the results in research. At one point, Dr. Gupta writes, “In 2005, the AHA’s [American Heart Association] guidelines for treating cardiac arrest were rewritten, as they are every five years, and they did list therapeutic hypothermia as a recommended treatment – but still not that elusive standard of care.”

The problem for me is that this statement is not accurate, or at least not as reliable as one migh think. The publication that Dr. Gupta cites is “2005 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care” (Circulation 112, no. 24 (December, 2005): IV-136 – IV-138). Unfortunately, the pages don’t say that hypothermia is a “recommended treatment.” In fact, that section of the report isn’t really about hyperthermia as treatment at all. It’s about appropriate treatment when a victim is found who is already hypothermic. It does note (twice, actually) that “hypothermia may exert a protective effect on the brain and organs in cardiac arrest;” but it isn’t advocating cooling patients who are already cool, and it isn’t commenting on hypothermia as treatment.

Now, there is a section on “Postresuscitation Support” (pp. IV-84 – IV-88). That includes several paragraphs on “Temperature Regulation,” and they do address induced hypothermia. This section does recommend therapeutic hypothermia, but not broadly. Rather,

In a select subset of patients who were initially comatose but hemodynamically stable after a witnessed VF [ventricular fibrillation] arrest of presumed cardiac etiology, active induction of hypothermia was beneficial. Thus, unconscious patients with ROSC [recovery of spontaneous circulation – the heart restarted] after out-of-hospital cardiac arrest should be cooled… for 12 to 24 hours when the initial rhythm was VF…. (emphasis mine)
This limited recommendation is based on two studies, at least as cited in the text. In both studies more patients did well among those who received hypothermia than among those who didn’t. However, it’s important to look at the exclusion criteria – that is, to know what cardiac patients they didn’t include in the study. In one (1),

Patients were excluded if they met any of the following criteria: a tympanic-membrane temperature below 30°C on admission, a comatose state before the cardiac arrest due to the administration of drugs that depress the central nervous system, pregnancy, response to verbal commands after the return of spontaneous circulation and before randomization, evidence of hypotension (mean arterial pressure, less than 60 mm Hg) for more than 30 minutes after the return of spontaneous circulation and before randomization, evidence of hypoxemia (arterial oxygen saturation, less than 85 percent) for more than 15 minutes after the return of spontaneous circulation and before randomization, a terminal illness that preceded the arrest, factors that made participation in follow-up unlikely, enrollment in another study, the occurrence of cardiac arrest after the arrival of emergency medical personnel, or a known preexisting coagulopathy.
In the other (2),

The exclusion criteria were an age of less than 18 years for men, an age of less than 50 years for women (because of the possibility of pregnancy), cardiogenic shock (a systolic blood pressure of less than 90 mm Hg despite epinephrine infusion), or possible causes of coma other than cardiac arrest (drug overdose, head trauma, or cerebrovascular accident). Patients were also excluded if an intensive care bed was not available at a participating institution.

Two things strike me about these sets of exclusion criteria. One is that they differ, making it more difficult to connect their data and generalize from it. The second is how carefully they narrow the types of patients with possible heart attacks who were actually studied. So, as the AHA Report says, “a select subset” showed benefit, and not a broad spectrum of patient unconscious after heart attacks. This is, of course, a common step in research. However, each exclusion adds another group of patients for whom it’s hard to argue the benefits of induced hypothermia.

Perhaps that progressive narrowing of “a select subset” is the reason for this comment in the last section of the AHA guidelines, “Major Changes in the 2005 AHA Guidelines for CPR and ECC,” by Hazinski et al (Circulation 112, no. 24 (December, 2005): IV-206 – IV-211): “Because of the challenges in the practical application of therapeutic hypothermia, further research is needed to identify optimal methods of cooling and optimal timing, duration, and intensity of cooling that is likely to be effective.” (p. 209)

So, it’s clear from what research we have that there are definitely patients who can benefit from therapeutic hypothermia. What we don’t know yet is how to determine who will and who won’t. It’s that lack of clarity that calls for more research before this could become the standard of care in postresuscitation care.

Now, for Dr. Gupta the physician that should be obvious. However, for Dr. Gupta the journalist it’s glossed over, in the interest of the story.  That's unfortunate, because it's particularly important for the wider reading public in understanding when this might be appropriate and available, and when it might not - specifically, when it might not be appropriate for someone they love.

An notethat I raised the question of availability.  Availability is one of the "challenges" cited in the "Major Changes" article by Hazinski et al.  For not only hypothermia, but also for almost all the new and "miraculous" procedures Dr. Gupta reports on, availability is a major issue (changes in standards for CPR are the noteworthy exception).  In his anecdotal reports, patients have access to major research hospitals, whether by proximity, by insurance, or by the interest an individual physician takes in the case.  For most patients, and certainly for most who might read this book, those resources are simply not going to be available.

As I said, this is an interesting and readable book.  Unfortunately, for all the qualifications of Dr. Gupta the doctor, this book from Dr. Gupta the reporter shows all the shortcomings of health journalism.  It brings out possibilities well before they're going to be generally accepted, much less available.  It highlights the successes without making clear the limitations, and especially the limitations in how many patients might actually be appropriate recipients of the therapies.  Finally, while it uses research to support the story, it does so poorly, relying primarily on anecdotal reports and using published research imprecisely.  Yeah, it's an interesting read.  Unfortunately, it might just create more problems than it solves.

(1) “Therapeutic Hypothermia after Cardiac Arrest,” the Hypothermia after Cardiac Arrest Study Group , Bernard S. A., et al, New England Journal of Medicine 346: 549-556, February 21, 2002.

(2) “Treatment of Comatose Survivors of Out-of-Hospital Cardiac Arrest with Induced Hypothermia, Stephen A. Bernard, M.B., B.S., et al, New England Journal of Medicine 346: 557-563, February 21, 2002.

Worthwhile Reading from a Colleague

I'm proud of my posts at Episcopal Cafe, but in addition sometimes one of my colleagues posts something of particular interest for chaplains. So, take a look at this post by Dierdre Goode. It tells of her family's experiences with hospice in England as her father was dying. It is moving, and shows, I think, how care should be provided.

Tuesday, January 12, 2010

Asking the Important Questions of Pastoral Visitors

So, there's been a visit to the House of Bishops of the Anglican Church of Canada by two Pastoral Visitors from the Archbishop of Canterbury.  They have, we are told, prepared a report for Archbishop Williams.  However, we haven't seen the report.  So far, all we've seen is a news article in the Anglican Journal that quotes from the report.

Like all other such events in the Anglican world, this has occasioned great discussion.  It's been reported at Episcopal Café.  It's been the topic for long discourse at Thinking Anglicans.  Mark Harris has raised his own questions.  The Pluralist has speculated about what might have been said in the report (to, I will say, great effect). But, all of this has been based on the one Anglican Journal article.  Again, we haven't seen the report.

My own reflections are based on the article as well, but specifically on passages in the article that are cited as quotations from the report itself.  I have raised these questions elsewhere, but I think they're perhaps the most important.

First, let me look at the comments about us Episcopalians.

The visitors said they were also reminded frequently by bishops that "Canada is not the USA." While the United States is seen as a melting pot culture where religious and ethnic groups are synthesized into "Americans," Canadians "genuinely value and seek to live with diversity."  Differences between the Anglican Church of Canada and The Episcopal Church were underscored, including the area of Christology. "We sensed that in Canada there was a general consensus on the nature of orthodoxy, with fewer extreme views of the kind that have led to some of the aberrations south of the border," the report said. "Even the bishops who were strongly progressive in the matter of same-sex blessings insisted that they stood firmly within the creedal mainstream." This, the report said, is "an encouraging sign that it allows for a more obviously Christ-centered approach to issues that currently divide the Communion, to say nothing of the wider church."

I want to hear, whether from Canadian bishops, Canadian theologians, or the Pastoral Visitors, just how the Episcopal bishops and the ACoC bishops differ on Christology.  We've been arguing for along time that the issues that divide us are largely matters of discipline, and not matters of Creedal theology.  Even the Canadian report on these issues has spoken of them as "matters of doctrine, but not of core doctrine."  It seems to me that Christology is a matter of first-order, and suggestions that Christology differs between two national churches within the Communion are a serious concern.

By the same token, we have argued that not only are our bishops "within the creedal mainstream," but that our "aberrations" are specifically and deliberately "Christ-centered."  Our reference to the Baptismal Covenant should speak to that, even in churches within the Communion that don't use it (and, by the way, the Church of England does use it, if within more limited contexts than the Episcopal Church).

So, allegations that we differ on Christology, and that we aren't centered on the Creeds, call for a more specific description.  Simply thrown out off hand in the inferences of these Pastoral Visitors, they are scurrilous, and as scandalous as the "extreme views" that Visitors apparently deplore.  True, these are allegations that we have heard before; but those who have made them have failed to actually point out how our actions alter the Church's understanding of the person and work of Christ, or how they alter understanding of the Creeds.  Pastoral Visitors from Canterbury ought to meet a higher standard.

By the same token, I wonder how Canadian bishops respond to this point, much less Archbishop Hiltz and include this in describing the Report as "good" and "accurate:"

[The report] Reiterated an earlier observation made by the visitors that the meeting of bishops was "relaxed and relational," and that while this has merits, "one casualty of this user-friendly meeting was perhaps a certain lack of theological depth." It noted that "very few of the items discussed were approached via theological first principles, the stress being much more on pragmatic outcomes."  While this may be "unduly critical," the visitors said, "we do not believe that the House is not without its theological heavyweights." Rather, they simply question "whether their expertise is made as widely available as it might be…"

This seems to me to be a classic example of damning by faint praise.  Are they suggesting that there is no "theological depth" behind the "stress… on pragmatic outcomes?"  True, they acknowledge (albeit grudgingly) that there are "theological heavyweights" in the Canadian house; but the clear implication is that the House as a whole, and most bishops within it, aren't doing their theology.

This suggests narrowness in the perspective of the Pastoral Visitors.  The first is that the format of a "relaxed and relational" gathering is unfamiliar to the Visitors.  Perhaps they expected more of a formal theological lecture, followed by intellectual discourse on "first principles."  Certainly, that's one way of approaching things.  Perhaps, too, the Visitors continue the neo-Platonic tradition within the Church that we deduce actions from principles, instead of inferring principles from observation (as I think the Romans do).  However, one would expect the Visitors to be able to discern other ways of functioning, and to ask intelligent questions when they don't understand.  Again, Pastoral Visitors for Canterbury should meet a higher standard.  (I think it also speaks to ecclesial issues,  expectations that bishops rather than General Synod should direct the Church, a criticism we've certainly heard here; but that's not as clear.)

So, what are we to do with this partial report on the report, lacking context?  Many are expressing outrage at another slap at the Episcopal Church, and at what they see as an effort to divide Anglicans in the Episcopal Church and Anglicans in Canada.  Perhaps those things are true, but I'm still more worried about the questions I see as more critical.  How are we differing on Christology, and on interpretation of the Creeds?  How are their approaches Christ-centered when ours are not?  How are the deliberations of the Canadian House of Bishops somehow not theologically grounded, or not "theological enough?"  The report of the Pastoral Visitors should be explicit on matters so important.  If it's not, neither Canterbury or the rest of us in the Communion are well served.  They're simply unfounded, unexplored allegations, of the sort we've heard for years.  Yes, others have said such things; but Pastoral Visitors for Canterbury should meet a higher standard.

Monday, January 04, 2010

On Reflection at the Turn of the Year: 2 - GOE's

I continue with another reflection on thirty years, then and now.

As I publish this, candidates for ministry are taking the General Ordination Exams (GOE’s).  The Canons of the Church require that an ordained person be competent in seven areas of study: Scripture; Church History; Theology; Ethics and Moral Theology; Studies in Contemporary Society (in my day called Church and Society); Liturgics; and Theory and Practice of Ministry.  While not required by all dioceses (some have alternative processes), for most of us the GOE’s were and are the critical demonstration of our competence.  Pray for all those taking the GOE’s this week.

As with any other educational endeavor, the GOE’s have changed over the years.  I’m not suggesting better or worse here, although at least one change I think has been an improvement.  I’m just conscious that the experience now is not the same.

Thirty years ago, the GOE’s were as much a physical challenge as an intellectual one.  Remember, this was in those ancient days BC: Before Computers.  However, we were expected to produce two perfect copies.  Almost everyone employed a professional typist, one who was prepared to type well, quickly, and late into the night.

The last was no small thing.  This is how the program worked.  The greatest part of the GOE’s was made up of complex, open book tests.  On Day One, a Monday, we received a page of questions, of which we were expected to answer three. We had 48 hours to research and write our responses, have them typed and copied (blessedly, copy machines had been invented; blessed were our predecessors who had to contend with carbon paper), and turned in on Day Three.  Day Four was divided between a morning of short essay questions using only Prayer Book and Bible and an afternoon multiple-choice test of 180 questions in 120 minutes – some hope of an objective measure in the midst of what was essentially a subjective evaluation.   At the end of the day we received another page of questions, to be completed and turned in on Day Six.  Day Seven was Sunday, and we had a day of rest.  Then on Day Eight we received another set of questions to be turned in on Day Ten.

The questions were more programmatic than academic: “Plan an eight week adult education program for Sunday mornings on the subject of Christology.  Include suggestions for hymns and prayers for the Eucharist to complement the program.”  Two questions have stayed with me over the years, one from my own GOE’s and one from GOE’s of a previous year, given to us as a mock test.  The first was, “A woman has come to you saying that she hears a voice talking to her, and she thinks it might be God.  How would you respond to her?”  The second was, “Mrs. Smith has called you at 2:00 a.m.  She says that she has come to understand that the Junior Warden is having an affair, and she wants to know what you’re going to do about it as Rector.  She says, too, that if she is not satisfied she may withdraw her $50,000 pledge toward the new Education Wing of the Church.  How will you respond to her?”

About twelve years ago, I had the opportunity to proctor a candidate taking the GOE’s outside the context of a seminary.  I was struck by how things had changed.  Granted, there was no need for a professional typist, what with computer editing and all.  However, I noted more that the questions were more academic than programmatic.  More significantly, the questions were no longer open book.  The candidate had access to Bible and Prayer Book, but to nothing else.  It was a better measure, perhaps, of what information the candidate had retained after graduation from seminary.  It was not perhaps as good a measure of the candidate’s creativity in applying that information in practice.

Again, I’m not making a comment that one exam model was better than the other, although I completely approve of making GOE’s less of a marathon experience (no, I’m not one to say, “It was good enough for me, so….”).  Rather, I think it suggests shifts in what the General Board of Examining Chaplains and others responsible for setting educational standards think the Episcopal Church needs.  I’ve lived long enough to know that such shifts take place over time, both in the Episcopal Church and in the larger community.

Once again, pray for those taking the GOE’s this week.  Pray, too, that the Episcopal Church might continue to be served by a body of educated clergy; and that the Episcopal Church might appreciate and support the education needed to keep such a body prepared to serve.