Prisoners and the healing power of compassion

We live in a society in which suffering, both physical and emotional, is considered something to be avoided at all costs. That drives the push for legalized euthanasia. It is also behind the tendency to treat normal emotions such as grief as an illness as Joe Gibes noted in his post on 2/24/12. When Christians look at suffering we understand that it is not in itself good, but that God can use it for good. Commonly what we mean by that is that God can help us to grow in our relationship with him by how we learn to depend on him as we deal with suffering. That is true, but there is another way that suffering can benefit people. It can benefit those who help others deal with their suffering.

An interesting article in the New York Times on 2/25/12 explores the need for prisons to deal with aging prisoners with life sentences who develop Alzheimer’s disease and other dementias. Different states have dealt with the need in different ways. California has developed a program in which prisoners, many of them also with life sentences for murder, but who have clean behavioral records, are trained by the Alzheimer’s Association to care for the needs of prisoners with dementia.

The thing that struck me was how the prisoners who were given the responsibility of helping those with dementia were impacted. One said, “A year ago, I couldn’t have said, ‘You know what man, I’m going to go help this grown man get in the shower.’” Another said, “I’m a person who was broken,” dementia patients often “don’t even say thank you,” but “they just pat me like that and I know what that means.” A third one said, “I didn’t have any feelings about other people. I mean, in that way, I was a predator. Now, I’m a protector.” One wrote in an evaluation, “Thank you for allowing me to feel human.”

We need to remember that we are all part of a community. When we think of how God can bring benefit out of suffering, it is not just that we can learn from our own suffering. It may be the ones who provide care for those who are suffering who benefit the most. Compassionate caring can help us see a part of the image of God that is inside even those who have been most twisted by this fallen world.

Medical care costs and the entrepreneurial physician

Joe Gibe’s post last Friday about the incentives within US healthcare that drive the overuse of expensive technology made me think of an article I had read several years ago. In June of 2009 The New Yorker published an article by Atul Gawande describing his investigation of why McAllen, Texas had among the highest per capita Medicare costs in the country. He compared McAllen to the demographically similar city of El Paso and interviewed people involved in health care in both communities. His conclusion was that McAllen had an unusually large number of entrepreneurial physicians. These were physicians who saw medicine primarily as a source of revenue and who many times made much of their income from other things besides direct patient care.

He reached this conclusion after finding that the difference between McAllen and El Paso was that there was higher utilization of services for patients with the same medical problems in McAllen than in El Paso even thought the populations were similar and there was no evidence of those in McAllen having better results than those in El Paso. The thing that was different was how the physicians looked at medicine. Many more in McAllen saw it primarily as a business.

The point is not that being an entrepreneur is bad. There are many ways that we as a society benefit from those willing to take on risks and try new ventures. It just is not a good mix with caring for patients. To function well the practice of medicine needs to be a profession that is focused on doing what is best for the patient. We see that in the long tradition of Hippocratic medicine. The current model of medicine as a contract between physicians, patients, and payers sees medicine as a business and encourages the physician to be an entrepreneur. It puts the focus on maximizing revenue and not on the best interest of the patient. Even those who enter into medicine with the intent to put the interest of patients first can get caught up in the pressures of this business model.

As we look at ways to improve our broken “system” of providing healthcare we need to remember the importance of promoting the traditional focus of medicine as being a profession founded on beneficence. Gawande observed that those places where the best quality medical care is provided for the lowest cost are those where there is an emphasis on putting what is best for the patient above everything else.

Washing dirty feet

One of the things I enjoy as a part of spending time on a Christian university campus after many years of full-time medical practice is the opportunity to participate in chapel. A recent chapel speaker focused on the account in John of Jesus washing his disciples’ feet. He noted that unlike modern foot washings in which we are likely to have cleaned our feet especially well before allowing someone to wash them, the disciples’ feet were quite dirty. They had walked into Jerusalem on roads traveled by animals as well as people. It made me think of what a person’s feet would be like after spending a few days in the sheep and cattle barns of a county fair walking around in sandals.

His point was that as we walk through life we pick up a lot of dirt and grime. When Jesus told the disciples to wash each other’s feet, he was telling them to help each other deal with the problems, failings, and sin that we pick up as we live in this fallen world. It is not that we focus on pointing out each other’s flaws, but that we develop the deep relationships with each other like Jesus had with his disciples which allow us to be close enough to help each other deal with the dirt and grime in our lives.

In medicine we have the opportunity to do things that can be a lot like washing dirty feet. Debriding infected foot ulcers or draining a putrid abscess fit the image. The relationship between a physician, nurse, or other caregiver and the one they care for allows an opportunity to get close enough to do the literal equivalent of washing feet. But we also need to recognize that those relationships allow for more than just physical care. We need to be attentive to the emotional and spiritual dirt and grime that our patients have picked up as the walk through life so that we can help them be washed emotionally and spiritually as well.

Human rights and euthanasia

The Parliamentary Assembly of the Council of Europe recently added an amendment to a resolution on advance directives to state that “euthanasia, in the sense of the intentional killing by act or omission of a dependent human being for his or her alleged benefit, must always be prohibited”. It is refreshing that the body charged with harmonizing the human rights laws among European states, and which bases its decisions on the European Convention on Human Rights, appears to have understood that the protection of human rights should lead to the prohibition of euthanasia.

Those who promote euthanasia see human rights in terms of individual autonomy and the ability of an individual to do whatever he or she wants. If we understand more clearly what is involved in human rights it is easier to see why those charged with upholding human rights should prohibit euthanasia.

Universal human rights are based on an understanding that all human beings have an inherent moral worth by virtue of being human beings. There are no characteristics other than being a member of the human family that are needed for a person to have full moral worth. The intentional ending of an innocent human life is a violation of the inherent worth of that human life. Since the inherent worth of every human life is the foundation of universal human rights, euthanasia is an attack on the foundation on which all human rights depend.

The Council of Europe appears to have made that connection.

Religious freedom and health insurance

On January 20, 2011 the department of Health and Human Services announced its ruling regarding a controversial part of the current administration’s healthcare plan. The health care plan includes a provision requiring all insurance providers to cover contraception at no cost to those who are insured. There is a religious exemption in the plan that allows churches who are morally opposed to contraception to offer insurance to their employees which does not provide this coverage. However, this exemption does not include church-affiliated organizations such as schools and hospitals. After the original requirement was made public last August, many church-affiliated organizations had requested that they be included in the exemption. The announcement a week and a half ago stated that such church-affiliated organizations would not be included in the exemption and would have to provide the coverage even if it violated the moral convictions of the organization. Those organizations were given an extra year before they have to comply with the regulation, but their compliance will be required.

This ruling is a significant attack on religious liberty in the United States. Religious liberty should include protection from being forced by the government to violate one’s moral values. It should include more than just the freedom to have beliefs. It must include the freedom to live in a way that does not violate those beliefs. Since the primary religious organization that has taken a moral stand against the use of contraception is the Roman Catholic Church, many see this is a purely Catholic issue, but it is much more than that. I do not happen to agree with the Roman Catholic position that says that all contraception is morally impermissible, but it is a well reasoned position based on fundamental parts of the Roman Catholic faith. As such their position should be respected, and they should not be forced by our government to violate their moral beliefs.

One part of the ruling impacts many non-Catholic church-affiliated organizations. The requirement for covering contraception includes drugs such as Plan B and Ella that are used after unprotected sexual intercourse to prevent a pregnancy from continuing if one has occurred. These medicines are not actually contraception because they do not work primarily to prevent conception, but to prevent the continuation of a pregnancy before the pregnancy is known to exist. Many of us to come from an evangelical Christian position find being forced to pay for these medicines just as morally objectionable as the Roman Catholic Church views other types of contraception.

It is interesting that when Robert George, Timothy George, and Chuck Colson drafted the Manhattan Declaration back in 2009 they chose to affirm three foundational moral principles which Christians from the Orthodox, Roman Catholic, and Evangelical traditions all supported. Those three principles were the inherent dignity of every human being, marriage as a conjugal union of man and woman, and religious liberty. I think there are many who may have wondered why they included the third principle as something on which Christians needed to take a stand. This ruling by HHS helps to make that more clear.

Exaggerated response to a limited clinical study

A preliminary report was published online on 1/23/12 in Lancet about the first two patients in safety studies of injecting retinal pigment epithelium cells derived from human embryonic stem cells into the eyes of patients with different kinds of retinal blindness. What can be concluded from the studies is that no tumor formation or rejection was noted in these two patients four months after the injections. That is not enough information to make any conclusions about the safety of this treatment and safety is the only thing these studies are designed to assess. There are some who have questioned why such limited data would even be published, but the headlines in the press were amazing. They ranged from “Early Success in a Human Embryonic Stem Cell Trial to Treat Blindness” (Time) and “Blindness eased by historic stem cell treatment” (New Scientist) to “Embryonic stem cells: can we make the blind see?” (Forbes).

Why would very limited initial results from preliminary safety studies have such an exaggerated response? Part of it undoubtedly has to do with our culture’s desire to find miraculous cures in science. In fact the Forbes article says “Restoring sight to the blind is, literally, a miracle…when the cells inside the eye are damaged, there is nothing we can do. Until now.” Another part may be due to economics. These studies are being funded by a private company, Advanced Cell Technologies, which stands to benefit from any positive publicity. The company’s Chief Scientific Officer, Robert Lanza, was quoted in the New Scientist article emphasizing the improvement in the vision of one of the patients. The studies are not designed to assess the effectiveness of the treatments to improve vision and vision was only measured to look for deterioration as a possible side effect. One of the other researchers involved noted that the other patient was found to have some slight improvement in vision in both of her eyes, even though only one was treated, suggesting any improvement was due to the immunosuppressant drugs used or a placebo effect.

Scientific discoveries can at times be very beneficial, but we need to take very preliminary studies such as this one as what it is – preliminary. We should not induce false hopes in people with retinal blindness that they are going to be cured. We should not forget that there may be some studies and treatments that should not be done, such as those which require the destruction of human embryos when other methods for deriving retinal pigment epithelial cells could have been used.

Costly grace and bioethics

I am currently reading Dietrich Bonhoeffer’s book, Discipleship, and thinking about how what he said relates to bioethics. One of the significant concepts in this book is the idea of costly grace. Bonhoeffer wrote “It is costly, because it calls to discipleship; it is grace because it calls us to follow Jesus Christ. It is costly, because it costs people their lives; it is grace, because it thereby makes them live. It is costly, because it condemns sin; it is grace, because it justifies the sinner. Above all, grace is costly, because it was costly to God, because it costs God the life of God’s Son – “you were bought with a price” – and because nothing can be cheap to us which is costly to God. Above all, it is grace because the life of God’s Son was not too costly for God to give in order to make us live.” (45)

One of the difficulties of Christian ethics (including Christian bioethics) is that when we focus on doing what is right it can seem like we are saying that doing what is right is necessary to gain God’s favor and that we are negating the foundational Christian doctrine of salvation by grace. That was a significant issue in Bonhoeffer’s Germany. The established church had taken a position which Bonhoeffer called cheap grace. They were saying that since God’s grace is freely given and we can do nothing to earn it, we should not try to do what is right, but should conform to the standards of society to show that our salvation is entirely free and not related to any effort of our own. That led them to conform to the Nazi regime’s practices that were engulfing their country and not to oppose them.

Bonhoeffer helps us to see that Jesus has paid the price for our salvation and that we can do nothing to earn it, but that God’s grace calls us to be disciples of Jesus. As we seek to follow him by the power of his Spirit and his transforming grace, we will seek to live by his standards. The moral reflection of Christian bioethics helps us to understand how God would have us live in response to his grace in our increasingly complex world.

Bonhoeffer, Dietrich. Discipleship. Minneapolis: Fortress Press, 2003.

Getting our priorities right

Sunday I had a decision to make. It was one of those small decisions that reflect our underlying priorities. Just as it was time to get up to get ready for church I received a call that a patient was being admitted to our local hospital under my care. She was stable and the ER doctor had written her admitting orders, but I did not know her and needed to see her to be sure her planned care was appropriate. I had several options. (1) I could go to see her before church and miss singing with the choir. (2) I could go to church and sing with the choir, but leave before Sunday School to see my new patient so I could be home in time to see the IU basketball game at noon. (You have to know how much I care about IU basketball to understand why this was a real consideration.) (3) I could go to church and Sunday School (which I knew was going to be a time of sharing concerns and praying for each other) and then go to the hospital and likely miss watching at least some of the game live. (4) I could wait until after the game and go to the hospital later in the afternoon.

At this point some may be wondering what this has to do with bioethics. There are no life and death choices here. There are no principles at stake that will change the course of our culture. But ethics is largely about the little decisions we make every day. It is about deciding which of the good things we do have the highest priority.

So what was I to do? I decided that for that morning my first priority should be worship and prayer. There are times that the care of a patient needs to come first, but in this case the patient was stable and her immediate needs had been taken care of, so she could wait until after the opportunity for corporate worship and prayer. My own entertainment could wait, so I set the DVR to record the game to watch later and went to see my patient as soon as we had finished our time of prayer.

Bioethics and Christmas part 4

I had originally intended to write 3 posts about bioethics and Christmas, but as I listened to our pastor talk about Mary on Christmas morning, I realized there was one more part to write. I have written about what we can learn about the value of human life, the particular value of unborn human lives and the hope we have in Christ, but I left something out, humility.

It is easy for us as we try to find the answers to bioethical dilemmas and struggle to express God-centered values in a world that has lost sight of moral truth to come across as proud and at times condemning. Christian bioethicists have a strong foundation on which to base solid ethical judgments. We have a passion for protecting the weakest of human beings that comes from God’s concern for those who are weak. But sometimes we (I) can come on too strong. Mary reminds us that we need to be humble.

When the angel came to Mary to tell her that God had chosen her to give birth to a boy named Jesus, who would be the son of God, she didn’t understand how that could be. After questioning the angel and being told that she would be overshadowed by the power of God, Mary responded humbly by saying “I am the Lord’s servant. May your word to me be fulfilled.” (Luke 1:38) Later as she sang her praise to God she remembered her own humble state and that God is the one who lifts up the humble.

When I reflected on these thoughts Sunday and planned what I would post on Wednesday I must confess to some pride about my insight into humility. How human I am to be proud of humility. Then with being off work for the holidays I managed to forget that yesterday was Wednesday and forgot to write this post. I am writing it today with a little more humility.

God’s moral truth is powerful, and we need to express it to a world in need of that truth. But we need to remember that we are just servants and approach each issue and each person with humility, realizing we are totally dependent on the grace of God.

Bioethics and Christmas part 3

Over the last two weeks I have been reflecting on how Christmas relates to bioethics. My thoughts were focused on how Jesus’ incarnation helps us understand the inherent moral value of every human life and particularly the value of unborn human beings. But I think there is another way that Christmas relates to ethics that may be even more significant.

One of the problems with ethics in general and bioethics in particular is that none of us lives up to even our own ethical standards. All of us, whether Christian or not, understand that there are ethical standards that we ought to live up to, but we are not able to do it. Ethics by itself raises the problem of our being unable to live up to ethical standards, but it doesn’t give us a good solution. One way to respond to our inability to live up to ethical standards would be to give up in despair. Jesus’ incarnation gives another alternative, hope.

When the angel announced Jesus’ birth to the shepherds outside of Bethlehem, the message was “I bring you good news that will cause great joy for all the people. Today in the town of David a Savior has been born to you; he is the Messiah, the Lord.” (Luke 2:10-11 NIV) The joy in that message is based on the hope it provides. The angel gave us the answer to the problem raised by ethics. Since we all fall short of both our own standards and God’s, we need help. The angel announced that the help we need is the Messiah who has come to be our savior. Instead of despair at our inability to live up to moral standards there is hope, hope that begins with the arrival of God in the form of a baby born in a stable and lying in a manger.

Glory to God in the highest!