Reflections From the Front: Kinder and Gentler (Corrected)

Reflections from the Front: a Kinder, Gentler Face

Bob Cranston, MD

Last month in Deerfield at CBHD’s 19th Annual Summer Conference, Paige Cunningham, Executive Director of the Center for Bioethics and Human Dignity introduced Dr. Charmaine Yoest, President of Americans United for Life, and listed a number of venues in which she had spoken winsomely to a less than receptive audience.  As she concluded her introduction, she said that Dr. Yoest had built many bridges, and represented “The kinder, gentler face of the Pro-Life Movement”. What a tribute to a talented woman who stands on and for her principles daily, yet maintains collegial relationships with many who are diametrically opposed to her philosophical and spiritual tenets.

Yesterday, along with several colleagues I lectured to a group of doctors who aspire to improving their educational presentations. We told them that when speaking to outside audiences, to best relate to listeners, they were to focus on: 1) patients first, 2) their institution second, 3) their specific discipline third, and lastly, 4) themselves.

Specific tips and pointers included:  1) respect your audience, 2) use fewer slides and speak more slowly, (no more than 1 slide per minute, optimally two minutes per slide),  3) use fewer words per slide, (28 point font or larger), 4) allow time for questions, 5) gauge and speak to the level of knowledge of your listeners, 6) engage your audience, 7) don’t feel embarrassed or stymied if you don’t know the answer to every question, but promise and then get back to your listeners with more complete answers as soon as possible, 8) repeat important concepts, and 9) leave them with your business card—a  way to get back to you with ongoing or further questions in the days and weeks ahead.

As I reflect on these principles, and Paige Cunningham’s description of Dr. Yoest, I am certain that she employs these and similar techniques in her public speaking, even as we all should when we represent Christian Bioethics and Christ himself to those who speak loudest against all we hold dear. As we focus on the needs of our listeners, the wonders of our Christ, the beauty of his church, and lastly on ourselves, we should show great respect, use fewer words, know and engage our listeners in real dialogue, be unafraid of not having all the answers, and keep the door open for ongoing conversation. We should all aspire to be the kinder, gentler, face of Jesus.

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Reflections from the Front: Suffering and Quality Control in the Church

 

Suffering

The Christian doctor lives in two worlds, and unlike the secular physician, often speaks with well-meaning people who offer inane consolation because they are unwilling to live with the paradox of a Loving God, and terrible human circumstances. It takes humility to tell your patients you don’t know the answer, and likewise, in the fellowship it requires trust and humility to acknowledge our lack of comprehension, but continued faith.

Quality Conrol in the Church

When you circle the wagons, the guns should point out—

But if you don’t police your own, who will?

 

When minds dement, spouses suffer, or children die,

Life is painful, and answers evade us.

If God is Sovereign—why do we hurt so badly?

 

“He always was a little arrogant about his intellect,”

“God may be purging hidden sin from her life,”

“He needed another cherub for his heavenly choir”

 

Poor answers are far worse than none at all.

The best words are often

“I’m sorry for your pain. I can’t even imagine how much this hurts.”

 

“We see through a glass darkly…”

And until we all see clearly,

 

We should avoid offering any manner of false comfort,

Confront and correct “Job’s Comforters” in our fellowships,

And remember it’s fine to say “I don’t know why, either.”

 

Reflections from the Front: Personhood and the Cryopreserved Embryo

Reflections from the Front: Personhood and the Cryopreserved Embryo

Bob Cranston, MD

The annual conference of The Center for Bioethics and Human Dignity in Deerfield, Illinois focused last week on women’s health issues and bioethics. A topic for future consideration will be gender-specific abortions, but this week we will look at Cropreserved embryos.

Epidemiologist Reginald Finger and reproductive endocrinologist Robert Visscher, shared information on embryo donation, and referenced Embryodonation.org/neda as an important reference site for information regarding embryo donation.

At present, the federal government estimates that there are 612,000 cryopreserved embryos in the United States. Eggs themselves remain technologically difficult to handle, and the cryopreservation process destroys most of these.  Of the 612,000 embryos about half are still “wanted” by their parents. The other half will likely be donated for procreation, donated for research, or destroyed (with or without an appropriately respective ceremony).

The primary question which dictates moral the worth of an embryo revolves around when “Personhood” or “Full moral agency” is perceived to be established. Scripture would seem to point to fertilization, or perhaps syngamy, the fusing of the two independent pronuclei, as the time this arises. At syngamy the embryo contains 46 chromosomes, is self-directing, and communicates chemically with the mother, informing her of its presence. A few scholars want to place personhood, from scripture, as late as birth itself. They rely on Genesis 2:7, where it says, “God formed man from the dust of the ground and breathed into his nostrils the breath of life, and man became a living being,” but this is a distinctly minority opinion.

While science concedes that life begins at fertilization or syngamy, it attempts to inappropriately argue from a scientific basis to a metaphysical conclusion. It variably locates personhood at: 1) Fertilization     2) Syngamy                  3) Implantation 4) Individuation (primitive streak appears) 5) appearance of heartbeat 6) quickening 7) Measurable brain EEG activity 8) Birth or 9) Sentience. Peter Singer, the most prominent proponent of the sentience position would allow infanticide well past birth. Those espousing position #8 would be comfortable with partial birth abortions.

Scripture and science should both be used to guide us, but science cannot speak authoritatively outside its purview. By our decision to place personhood at fertilization or syngamy we have a moral imperative to protect the life and health of these 300,000 embryos. The most obvious way to do this, though not simple or straightforward, is embryo donation and adoption. In a future blog we will look at  Dr. Finger’s analysis of other underlying moral issues related to these frozen embryos.

 

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Reflections from the Front: In Praise of the Open Casket Wake

Reflections from the Front: In Praise of the Open Casket Wake

In the Philippine Islands, where I grew up, when a family member died, the family would place the body in a casket, with the face visible for viewing, and hold a public mourning period for nine days in the home. While the word Novena may be used to mean praying for nine straight hours, it can also be used to mean praying consecutively for nine straight days. Neighbors, friends, family would stop by, pay their respects, weep, pray and commiserate with the family for nine days prior to burial.

In Judaism, “sitting shiva” is a seven day process during which one mourns deeply and publicly for a parent, sibling, spouse or child. Family and friends attend to the spiritual, emotional and physical needs of the bereaved, and members of the community drop by the house of the surviving family members for short “shiva calls” which have specified styles and forms of shiva grieving.

Many kind people streamed by the caskets of my father, mother, and later on, my wife on the days prior to each of their burials. It was good to hear from various people of the kind things these loved ones had done, unbeknownst to us, that had touched the lives of others. It was also good to hear encouraging words from the Body of Christ. It was good to explain to children that they would see their teacher again, with a strong new body, in a much better place.

Recently, I heard of a local devout Christian man, who strongly desired to be cremated, and wanted no one to view his body. Pictures of Larry, at an earlier, healthier time, were displayed at the funeral. He said he didn’t want anyone to remember him as he had become, but as he had been. While I could empathize with his feelings, I felt he was missing a powerful opportunity.

When I die, I want to have an open casket wake. I want people to see that I don’t look nearly as strong, young, and handsome as I once was. I have already lost a lot of ground, and will certainly lose more before I die. I want people to recognize that for most of them, this same process will occur. But this isn’t really so sad; it is a part of God’s plan for our physical lives. We grow, we flourish, we wane, we die, and we are born to eternal life. My wasted body and aged visage will be a vivid reminder that this is not the end. We are not home yet. God has big plans for us! The resurrection changes everything!

And hopefully some of them will have nice stories to share with my children.

 

 

Reflections from the Front: Care of the Poor

Reflections from the Front: Care of the Poor

In a recent article on this blog site, http://blogs.tiu.edu/bioethics/2012/06/08/undocumented-immigrants-and-health-care/, Dr. Joe Gibes raised an important question about undocumented aliens and their need for healthcare. This is a difficult problem, a complex issue. In the first comment afterward, a writer states, “Agreed. Illegal or not, they are still people who have the right to see a doctor or go to the hospital. This is one of the reasons why we should have universal healthcare…”

In “The Tragedy of American Compassion”, Marvin Olasky (Regenery, Gateway, 1992) takes us to an earlier time in America when care of the poor fell largely to churches and other charitable bodies. Most Americans do not believe that solving the health crisis in America will be best done by the federal government. I think it can be too easy at times, whenever a legitimate criticism is raised about our current medical system to suggest that this is “why we should have universal healthcare…” While there clearly are problems with our present system, it is not at all clear that a federal program will solve these problems.

Truly complex problems seldom have simple straightforward solutions. For a more nuanced discussion of this issue, I would recommend: http://www.balancedpolitics.org/universal_health_care.htm, though I will concede in advance that few who advocate strongly for a federal solution to our crisis will deem this site “balanced.” It will at least give you food for thought and illustrate how complex the issue really is.

  • In the meantime are you involved in civil civic discourse on this issue? Much public debate has become only vitriol.
  • In the meantime, are you involved as a local church in helping to meet healthcare needs in your community? Parish nurses, pro bono care, and local sliding scale clinics may be instrumental in meeting human need.
  • In the meantime, do you support local, non-governmental solutions to local problems? Dr. Olasky, rightly or wrongly, points to local, Christian solutions as our only real hope.

We as individuals certainly can’t solve the whole problem, but we may contribute to a solution. And we can seek a solution in a civil, non-demeaning, rational manner.

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Reflections from the Front: Jonah and the Call

Reflections from the Front: Jonah and the Call

Our pastor just finished a series on “Jonah the Reluctant Prophet.” God’s call to Jonah was crystal clear, “Go to Ninevah!”  But Jonah didn’t want to obey. He had his reasons: the Assyrians were a vile, violent, ruthless people who had persecuted Jews historically and who would eventually drag Israel into a brutal captivity. Yet God was clearly calling Jonah to action and Jonah refused to cooperate with God’s plan.

We are all called to God himself: to obey, worship and glorify him, and to evangelize and make disciples. We may be called to marriage, parenthood, or the care of our parents— the only one of the Ten Commandments with a promise.  Many of us are called to become physicians. Here our day-to-day functions may evolve over time: busy clinician, counselor, educator, mentor, and leader. Leader?

In our Christian subculture, becoming a missionary doctor is often given special, if not top billing, as far as a call goes. God uses Christian medical leaders in foreign mission settings; but he also uses Christian medical leaders here at home. Jesus urged his disciples to serve him in Jerusalem, Judea, Samaria, and then unto the uttermost parts of the earth. Has he called you to stay home and be his voice in Jerusalem?

“Real doctors,” especially young physicians, often see the physician-healer role as the most desirous, rewarding, even the most noble profession. I resonate. But recently God made clear a new call to me—coaching and overseeing doctors to help them serve others better here in the United States. He has asked me to multiply the benefits of my experience in the lives of others. (He has allowed me to maintain an active part-time medical practice, so I guess I am really a player-coach.)

The role of administrative physician is not seen as being very jazzy or highly desirable. It is not portrayed on any prime time TV show—there are few overwhelming crises, and none that can be solved in 48 minutes. Having said this, medical administrators can be salt and light to a large group of needy people, many of whom, if properly nurtured and motivated, can serve their worlds in a deeper, richer way.  Hopefully, the doctors, nurses, patients and hospitals that you will serve in this role will not be as vicious and ungrateful as Jonah anticipated his target audience would be. Regardless, there is no better, safer place to be than in the center of God’s will. If this is where God is calling you, it is where you should be. If you are unaware or uninformed about this option it is hard to seek the Lord’s will about pursuing this.

I’m certain this brief essay will push few of you into the career he has called me to, but we need godly Christian woman and men in these leadership roles. If God is calling you to this kind of “secular” leadership role, carefully confirm his leading in your life, but don’t sail off to Tarshish. You are needed in Ninevah.

 

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Reflections from the Front: Truth Will Out

Reflections from the Front: Truth Will Out 

Dimitrios Karussis, in “Worldwide Status of Clinical Experimentation with Stem Cells in Neurologic Disease”, Neurology 78, April 24, 2012, Pgs 1334-6, discusses current world-wide stem cell research.  He introduces embryonic stem cells in his first paragraph, only to dismiss them quickly, ”…the transplantation of undifferentiated stems cells cannot provide a first-line option for clinical applications since it is associated with a high risk of potential carcinomatous transformation.” With the remainder of the review he focuses on adult stem cells, which provide a present and future hope for relief or cure for many diseases.

A few years ago in American academia, the “known truth” among intellectuals was that embryonic stem cells were the only real hope of the future. In a symposium I attended on the University of Illinois campus, 12 of 13 experts all confirmed it. The lone dissenter was a Roman Catholic campus priest. In another symposium I participated in, when I observed that no significant breakthroughs had been made in treating people with embryonic stem cells, and that adult stem cells already had shown great success, the discussant noted that since I was only a clinician and not a scientist, I couldn’t possibly understand the arguments. He did not attempt to engage my truth statement.

Two logical fallacies were employed in these settings. First, the appeal to authority fallacy, “since all the experts agree, we know it is true.”  Secondly, the ad hominem approach “since I cannot attack your reason I will discredit you.” But as we know, the passage of time has vindicated the wisdom of our position.

In John 7: 45-52, the Pharisees used the same two ploys. First, “Has any of the rulers or of the Pharisees believed in him? No!” Secondly, when Nicodemus attempted to raise a legal objection about their attack on Jesus, their response was to attack him, “Are you from Galilee, too?” Interestingly though they chose to disbelieve, they based their criticism partly on their mistaken notion that Christ was born in Galilee. They were all in agreement, but had their facts wrong.

There are many who will choose to refuse the truth, but time will prove the veracity of our faith. So for those of you engaged in the daily battle for truth in the public arena, remember to “not grow weary in well doing for in due season ye shall reap if ye faint not,” and that “Every knee shall bow and every tongue shall confess that Jesus Christ is Lord to the glory of God the Father.” Truth will out.

 

Reflections from the Front: Treating Family Members

Reflections from the Front: Treating Family Members

In my last few blogs I have been addressing different aspects of the broad concept of conflicts of interest. To continue, though really in a different vein, when is it appropriate for a medical provider to medically care for a close friend or family member? This is a somewhat controversial, old but new question that has recently shown up again on our ethical radar.   http://www.ama-assn.org/amednews/2009/04/13/prca0413.htm

A few situations seem obviously concerning: Life endangering but necessary surgery on a loved one, procedures with permanent ramifications performed on a minor child, or overseeing experimental drug trials on a loved one come to mind.

Other scenarios seem more appropriate: emergently performing life-saving surgery when no other qualified surgeon is available, helping to oversee medical regimens in tandem with an unrelated physician who closely monitors progress, providing supportive non-surgical, non-pharmacologic treatment to dying family members, or refilling medications originally ordered by a treating physician who is temporarily unavailable.

What about cases in the middle? If you are the most qualified, skilled plastic surgeon available is it appropriate to perform elective cosmetic procedures on family and friends? Why or why not? This is not an easy question, and many plastic surgeons currently perform surgeries on their family members. http://www.ncbi.nlm.nih.gov/pubmed/20195128

Some considerations:

1)      Objectivity in treating patients is critical, and may be difficult if not impossible to achieve with loved ones.

2)      Unless you are facing an emergency, your children and your spouse need you more as a parent or spouse than as a doctor. There are other doctors who can help, but only one you.

3)      Consent may be complicated, raising questions of coercion, again.

4)      Failed therapeutic endeavors may permanently alter core family relationships.

5)      If despite providing the best possible care for your relative, mistakes happen (and bad things happen even without mistakes) not only may it alter core relationships, but it may prevent appropriate remuneration for injured parties.

6)      Compliance on the part of family members may be even more complicated than usual compliance issues.

7)      While in general it might seem fairly innocuous to volunteer your services for family members’ care, it is seldom as uncomplicated as it seems.

Reflections from the Front: Conflicts of Interest (Again)

Reflections from the Front: Conflicts of Interest (Again)

Lately a number of high profile stories on conflicts of interest have made headlines. One reported in Nature http://www.nature.com/news/editor-s-move-sparks-backlash-1.10068  relates how Glenn McGee, Editor-in-Chief of the American Journal of Bioethics recently was criticized for his paid position with CellTex Therapeutics in Houston Texas. Is it really okay for the senior editor of one of the world’s most highly quoted ethics journals, theoretically a neutral voice of wisdom, to hold a highly paid position in a controversial, for profit research company? Many bioethicists did not believe it was, and he subsequently resigned from the research position.

Many conflicts of interest are couched in financial terms. I cannot sell goods and services to the company for which I am the purchasing agent. I cannot publish research on pharmaceuticals from companies that I own stock in without disclosing this publicly. I cannot present a medical lecture to a small group of doctors and nurses without disclosure.  In fact, I am not to mention medications by their brand names for fear of creating undue influence on prescribers in the audience.

Some of this seems almost silly, but the underlying question is important. Can I trust this physician, researcher, or author to give me clean information? The most dangerous lie is the near-truth or the half-truth. Blatant lies are easily spotted and named.

Another aspect of this discussion is one I have discussed on this blog earlier. When I, as a treating doctor wear the additional hat of being clinical researcher, how do I keep my loyalties straight? Is this really the best course of action for my patient, or do I believe in the investigational therapy because I have a vested emotional or financial gain at stake?

Closely linked with this bias question is one of coercion. If you trust me as your treating doctor, I may have to say very little positive about the investigational treatment for you to willingly sign on. When you get home and your spouse or children question your decision, in all likelihood you will reply that you trust me, I’ve never let you down, and I wouldn’t recommend this for you if I didn’t believe in it. In fact, by the very nature or a treatment trial, I cannot officially be recommending it to you, nor can I know that it will be helpful. I may hope, speculate, and even believe it will help, but I certainly can’t tell you I know it will help. If I even hint this is true, I am engaging the placebo effect, warping any outcome assessment.

I am only musing, and don’t offer any substantive advice, except to caution that any time we are in a relationship with a vulnerable party our responsibility is greater, and in all doctor-patient relationships this is inherent.  We must be very careful how we say what we say, and to whom we say it.

Reflections From the Front: Chameleon

The Doctor-Patient relationship. On this day I had a guest with me in the office. Harvey was a community observer. I had been asked to work with him so he could better grasp what doctors do for a living. Each patient granted permission for Harvey to be present before our visits. Originally published in Carle Selected Papers, Volume 46, No 1, 2003)

 

Chameleon

 

At 7:55 Harvey, the community observer.

By pre-arrangement with the clinic administrator,

And with permission from the patients,

He would be my shadow for the day.

 

At 8:00 a 78-year-old lady presented with back pain, headaches and fatigue.

Mainly, she needed someone to talk to.

So, I talked with her.

 

At 9:00 we saw a 21-year-old alcoholic who had fractured his skull while driving drunk.

After two weeks in a coma, two months in rehab, and two months at home

He still had weekly seizures.

Mainly, he wanted me to sign his driver’s license form.

I refused. Firmly, but gently, I hoped.

I urged compliance. I refilled his carbamazepine.

I educated. I quoted favorable statistics.

I asked him to see me again in 3 months.

 

At 10:00 a 69-year-old man thought I was going to give him a pill for his tremor.

Instead, I told him about Parkinson’s disease.

How I knew he had it.

What we could do about it.

I gave him pamphlets and

The 800 number to call for information.

I told him about Johnny Cash, Janet Reno, Billy Graham, and Barry Goldwater.

I told him about Levo-dopa, the good and the bad.

I gave him a script, my number, and a follow-up appointment.

I told him to bring his wife next time.

 

At 11:00 a 23-year-old woman, 10 weeks pregnant, told me about her headaches.

In light of her pregnancy, our therapeutic options were limited.

But there were some things we could try.

We could walk her through this, I said.

Call us. We’ll see you often.

Over lunch hour, in the hospital, I met with a family.

Dad was on the ventilator, with no respiratory effort of his own.

His eyes were shut. His pupils were fixed. He did not respond to pain.

We had a long talk.

We prayed. I cried.

I would meet with them again in the morning.

 

There were ten people to see in the afternoon, all “follow-ups”.

Mainly we were friendly acquaintances, catching up on recent happenings.

I disliked two of them, in the way that we put up with odd relatives.

I cajoled. I confronted. I encouraged. I chuckled. I commiserated.

 

At 5:00, Harvey laughed long and hard.

“Blazes, Bob,” he said to me,

“You’re a chameleon. How can you be so many things to so many different people?”

 

I smiled.

I hadn’t thought of it that way before.

But, I realized, that was part of the appeal of this calling.

On the fly, could you scope out the need

And then figure how to help?

 

“I don’t always get it right,” I said.

“But on the days that I do, I feel like maybe, what I do matters some.

And I think I feel God smile.”