CMDA TODAY
Volume 52 • Number 1 • Spring 2021
Ethical Vaccines
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CEO Editorial Mike Chupp, MD, FACS
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Welcome to CMDA Today!
e hope you will enjoy the new look of CMDA’s quarterly journal under its new name, CMDA Today. This spring edition is the result of much planning, hard work and creativity on the part of our communications team, especially Mandi Morrin, our award-winning editor. This flagship news and education print magazine of CMDA began as a simple, regular newsletter from the Christian Medical Society to its members in 1941, so this name change, in part, celebrates 80 years of educating, encouraging and equipping followers of Christ in healthcare through printed communications. So why the change from Today’s Christian Doctor (the name of the journal since 1996) to CMDA Today? The most compelling reason is that the Christian Medical & Dental Associations has steadily grown into a more diverse healthcare membership organization that welcomes new members from a wide range of healthcare professional training and practice. While most of our members are physicians and dentists and their trainees from a broad spectrum of medical and dental specialties, we also have increasing numbers of physician assistants, nurse practitioners, podiatrists, optometrists, physical and occupational therapists, healthcare executives and administrators and several other disciplines. We hope this quarterly journal will appeal to a wide range of Christians on the healthcare team, not just “today’s Christian doctor.” Our vision of “bringing the hope and healing of Christ to the world” has been expanding to include a larger healthcare team. Our motto of “Changing Hearts in Healthcare” is about transformation in and through all healthcare professionals who sincerely desire to please God in their care of patients and their families every day. The focus of our cover story in this first edition of CMDA Today is on promoting ethical vaccines by Dr. Jeff Barrows and Jonathan Imbody. This article, which was originally published in the online journal Public Discourse and has been updated for you, is intended to better inform our membership about COVID-19 vaccine development as our country and the global community battle to end the pandemic through the administration of several FDA or other international authority approved vaccines. I believe most frontline caregivers who choose to be vaccinated will have been immunized by the release of this publication. We continue to include articles with continuing education credit, including an article in this edition about human trafficking. We are also excited to introduce a new column by Dr. John Patrick, longtime and beloved friend of CMDA, entitled “The Dr. John Patrick Bioethics Column.” This edition also includes an overview of our recent extensive member survey, written by CMDA’s Chief Operating Officer Jamey Campbell. In October 2020, we received feedback from more than
1,600 members and 700 non-members to assist the Board of Trustees and our administration in drafting a new strategic plan in 2021. We are most grateful for the investment of time that so many of you made to give us constructive comments to help us better serve followers of Christ in healthcare. One of the special focus areas in this survey was evaluating the need for CMDA to address issues of racism and diversity in healthcare after a year of crisis in 2020. The majority of respondents felt that CMDA should carefully and sensitively address issues of race-based healthcare disparities and diversity within the healthcare workforce in our nation today. Several of our readers also gave feedback after the fall edition of Today’s Christian Doctor on the cover article “Racism in Healthcare: No One is Immune” by Dr. Omari Hodge and Nicole Hayes, who are both members of CMDA’s new R2ED Committee (which stands for racism, reconciliation, equality and diversity). The survey results AND response to this article demonstrate a great concern by members that CMDA must avoid the influence of Critical Race Theory, which has taken U.S. culture by storm. The R2ED committee has formed a subcommittee to address this specific concern of our members in 2021 and beyond. As committee chair and a member of our Board of Trustees, Dr. Hodge is intent on helping CMDA steer clear of this deceptive yet popular philosophy, especially in academic circles. I encourage you to watch for future CMDA Today articles and CMDA Matters podcasts that will give us biblically-based and Christ-honoring principles of reconciliation with God, our co-workers from diverse ethnic backgrounds, our patients and our society at large. I’ll close by inviting you to celebrate CMDA’s 90th anniversary with us during the LIVE 2021 CMDA Virtual National Convention on April 29 - May 2, 2021. As we continue to battle the pandemic, we will not be meeting in person this year. Instead, I encourage you to join us for fellowship, encouragement and spiritual renewal at the virtual convention. CMDA began in 1931 when two Northwestern University medical students in Chicago, Illinois discovered they shared a desire to please God through their medical careers and began studying God’s Word together. We celebrate that God has kept that vision alive and well and has been “changing hearts in healthcare” for 90 years, to God be the glory! Mike Chupp, MD, FACS, is the CEO of CMDA. He graduated with his medical degree from Indiana University in 1988 and completed a general surgery residency at Methodist Hospital in 1993. From 1993 to 2016, he was a missionary member of Southwestern Medical Clinic in St. Joseph, Michigan, while also serving as a career missionary at Tenwek Mission Hospital in Kenya.
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VOLUME 52 | NUMBER 1 | SPRING 2021
EDITOR Mandi Morrin
EDITORIAL COMMITTEE Gregg Albers, MD John Crouch, MD; Autumn Dawn Galbreath, MD Curtis E. Harris, MD, JD Van Haywood, DMD Rebecca Klint-Townsend, MD Robert D. Orr, MD Debby Read, RN
CMDA TODAY
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CHRISTIAN MEDICAL & DENTAL ASSOCIATIONS P.O. Box 7500, Bristol, TN 37621 888-230-2637 main@cmda.org • www.cmda.org If you are interested in submitting articles to be considered for publication, visit www.cmda.org/publications for submission guidelines and details. Articles and letters published represent the opinions of the authors and do not necessarily reflect the official policy of the Christian Medical & Dental Associations. Acceptance of paid advertising from any source does not necessarily imply the endorsement of a particular program, product or service by CMDA. Any technical information, advice or instruction provided in this publication is for the benefit of our readers, without any guarantee with respect to results they may experience with regard to the same. Implementation of the same is the decision of the reader and at his or her own risk. CMDA cannot be responsible for any untoward results experienced as a result of following or attempting to follow said information, advice or instruction.
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Membership Survey Results
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CMDA is a member of the Evangelical Council for Financial Accountability (ECFA).
Undesignated Scripture references are taken from THE HOLY BIBLE, NEW INTERNATIONAL VERSION®, NIV® Copyright © 1973, 1978, 1984, 2011 by Biblica, Inc.® Used by permission. All rights reserved worldwide. Other versions are noted in the text.
on page 18
The Journal of the Christian Medical & Dental Associations
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CMDA Today™, registered with the U.S. Patent and Trademark Office. Spring 2021, Volume LII, No. 1. Printed in the United States of America. Published four times each year by the Christian Medical & Dental Associations® at 2604 Highway 421, Bristol, TN 37620. Copyright© 2021, Christian Medical & Dental Associations®. All Rights Reserved. Distributed free to CMDA members. Non-doctors (US) are welcome to subscribe at a rate of $35 per year ($40 per year, international). Standard presort postage paid at Bristol, Tennessee.
EARN CONTINUING EDUCATION CREDITS
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Jamey Campbell
Sharing feedback from our members
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ON THE COVER Ethical Vaccines: Ready for a shot in the arm?
First Fridays at the Mortons Paul Glaser, MD, PhD, FAAP, and Joyce Lo, MD, FAAP
How to get personally involved with local ministry
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My Hour Has Come! Larry H. Lytle, MD
Jonathan Imbody, MEd, and Jeffrey J. Barrows, DO, MA (Ethics) An in-depth look at the COVID-19 vaccines
Understanding the sacrifice of Jesus’ death on the cross
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Human Trafficking Paul Glaser, MD, PhD, FAAP, and Joyce Lo, MD, FAAP
Common Psychiatric Consequences of Human Trafficking on Children and Adolescents and Their Medical Management
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The Dr. John Patrick Bioethics Column
Seeing the Big Picture of Bioethics John Patrick, MD
A new column focused on bioethics and apologetics
See PAGE 34 for CLASSIFIED LISTINGS REGIONAL MINISTRIES
Connecting you with other Christ-followers to help better motivate, equip, disciple and serve within your community Western Region: Michael J. McLaughlin, MDiv • P.O. Box 2169 • Clackamas, OR 97015-2169 • Office: 503-522-1950 • west@cmda.org Midwest Region: Allan J. Harmer, ThM, DMin • 951 East 86th Street, Suite 200A • Indianapolis, IN 46240 • 317-407-0753 • cmdamw@cmda.org Northeast Region: Tom Grosh, DMin • 1844 Cloverleaf Road • Mount Joy, PA 17552 • 609-502-2078 • northeast@cmda.org Southern Region: Grant Hewitt, MDiv • P.O. Box 7500 • Bristol, TN 37621 • 402-677-3252 • south@cmda.org
CHRISTIAN MEDICAL & DENTAL ASSOCIATIONS ® Changing Hearts in Healthcare . . . since 1931.
Ministry News RESOURCES
Webinar Series
CMDA Go App CMDA Go, our new mobile app, is now available for you to download on Apple and Android mobile devices. Visit your device’s app store to download it today. In the new CMDA Go app, you can set up your personal CMDA profile, check out the latest news from CMDA, listen to CMDA Matters and other podcasts, renew your membership and make your dues payments, access a variety of downloadable resources, interact with other members through the discussion forms and join group chats. More information and new features will be released in the next few months. For more information, visit www.cmda.org/app.
CMDA Matters Are you listening to CMDA’s weekly podcast with CEO Dr. Mike Chupp? CMDA Matters is our popular weekly podcast with the latest news from CMDA and healthcare. A new episode is released each Thursday, and interview topics include bioethics, healthcare missions, financial stewardship, marriage, family, public policy updates and much more. Plus, you’ll get recommendations for new books, conferences and other resources designed to help you as a Christian in healthcare. Listen to CMDA Matters on your smartphone, your computer, your tablet…wherever you are and whenever you want. So make the switch today and start listening to the podcast on a weekly basis on your mobile device. For more information, visit www.cmda.org/cmdamatters.
CMDA is excited to be hosting a quarterly webinar series with The Hendricks Center at Dallas Theological Seminary. “CMDA and DTS Dialogues: Healthcare and Theology Learning Together” is a quarterly webinar series focused on discussing topics important to today’s leaders in healthcare and in the church. Hosted by Dr. Darrell Bock, each webinar includes a panel of experts to discuss topics such as the beginning of life, vaccine development, how COVID impacts the church and more. Upcoming Webinars • Wednesday, May 12, 2021 • Wednesday, August 11, 2021 • Wednesday, November 10, 2021 For more information about the webinar series and to register, visit www.cmda.org/dtswebinar.
Upcoming Events Dates and locations are subject to change due to COVID-19. For a full list of upcoming CMDA events, visit www.cmda.org/events. 2021 CMDA Virtual National Convention April 29 – May 2, 2021 • Ridgecrest, North Carolina Italy Tour May 23 – June 4, 2021 • Italy
Greece Tour May 28 – June 6, 2021 • Greece Israel Tour June 8-20, 2021 • Israel
Turkey Tour August 24 – September 3, 2021 • Turkey
Women Physicians in Christ Annual Conference September 30 – October 3, 2021 • Grand Rapids, Michigan
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Ministry News
CMDA Learning Center Have you visited the CMDA Learning Center yet? Offering complimentary continuing education courses for CMDA members, the online CMDA Learning Center is continuing to grow with resources and information to help you in your practice as a Christian healthcare professional. The CMDA Learning Center is dedicated to the inspiring memory of William “Bill” Lawton, MD, a wonderful friend of CMDA who was a physician, an educator and a minister. In his career in academic medicine at the University of Iowa for 40 years, Dr. Lawton served God faithfully in all three capacities and received numerous awards as he integrated his Christian faith with medicine. He impacted generations of young physicians-in-training as he modeled the art of caring for the whole patient. Bill cherished his continual membership with CMDA, which began as a medical student at Northwestern Univer-
sity. The ripple effect of his legacy extends far beyond Iowa; first and foremost, to his family and friends, and then around the globe through nearly a dozen mission trips with CMDA’s Medical Education International (MEI). Dr. Lawton also passionately stood for life as he opposed physician-assisted suicide. On several occasions, Bill shared his testimony at the Massachusetts Statehouse speaking truth as a physician and as a patient with Stage 4 pancreatic cancer. Above all else, Bill’s life goal was to reflect his Jesus. We prayer the CMDA Learning Center will glorify God by providing educational opportunities for Christian healthcare professionals in the U.S. and around the world. More than 100 hours of continuing education are now available at NO COST to CMDA members. For more information and to access the CMDA Learning Center, visit www.cmda. org/learning.
In His Image encourages and provides great opportunities for international rotations during residency. I explored the option of long-term medical missions while spending a month overseas during my second year of residency at IHI. The faculty physicians and many of the program’s graduates have extensive experience in international medicine and were enthusiastic in helping to provide me with training and counsel for my future. After graduating from IHI, my family and I moved to Malawi, Africa. My husband teaches at a village school and I work at a hospital in the capital, treating patients and training Malawian family medicine residents. We are so incredibly thankful for the guidance and experiences God gave us through IHI as we prepared for service in Malawi!
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Ministry News MISSIONS
STEWARDSHIP
PAACS Celebrates 25th Anniversary
Memoriam & Honorarium Gifts
In February 2021, the Pan-African Academy of Christian Surgeons (PAACS) celebrated its 25th anniversary. PAACS was founded in 1996, and since then, God has grown this ministry exponentially as it trains and disciples African surgeons to glorify God and provide excellent care to those most in need. As they celebrate the 25th anniversary, founder Dr. David Thompson rejoices that they have watched more than 100 graduates of their residency programs follow God’s call to serve in Africa. Dr. Thompson recalled, “Twenty-five years ago, God challenged a group of overworked missionary surgeons to take a giant step of faith. We had all come to the Brackenhurst Conference Center in Limuru, Kenya to attend a continuing education conference for medical missionaries, and Gerald Swim, a CMDA representative, invited me to share with the other surgeons at the conference a call to train African doctors in surgery and disciple them. That would require we establish formal surgery residency programs at our hospitals. There were only 10 of us, and only two of the hospitals represented at that meeting had more than one formally trained surgeon on staff. We had no money, no curriculum, no authorization from the countries where we served, no recognition from any of Africa’s colleges of surgery—but we had God on our side! The story of the miracles that God has done over the last 25 years and to this day to bring surgical excellence and the gospel of Christ to the people of Africa must be told. ‘Not to us, O Lord, not to us, but to your name goes all the glory for your unfailing love and faithfulness’ (Psalm 115:1, NLT).” In 2020, CMDA was excited to see PAACS grow into a standalone ministry as a non-profit organization. PAACS Executive Director Susan Koshy said, “With God on our side and dependence on Him during the next chapter of PAACS, all things are possible. It is our prayer that God will continue to use PAACS residents to impact Africa surgically, while touching many lives for His glory during the next 25 years.” To learn more about PAACS, visit www.paacs.net.
Gifts received July 2020 through September 2020 Memory
Jacquelyn Burlund in honor of Maggie Larsen Susan Lee in honor of Leon and Linda Lee BK Services in honor of Allan Josephson, MD Nicole Baldwin in honor of Heidi Drake and Jaime Fernandez Dr. and Mrs. Marvin R. Jewell, Jr. in honor of Stan Key Mr. and Mrs. Bobby R. Sluder in honor of Rusty and Melanie Sluder Mr. and Mrs. Emmanuel Hilario in honor of Drs. Paul and Jocelle Glaser’s 25th wedding anniversary Mr. and Mrs. James Sechrist, Jr. in honor of Andy and Ilene Sanders
Dr. Poh-Lian Lim in honor of Dr. Clydette Powell
Honor
Mr. and Mrs. Thomas Titkemeier in memory of Sandra June (Mays) Collins Mr. and Mrs. Thomas Titkemeier in memory of James Ophelt Mr. and Mrs. Jeffery Howell in memory of Phyllis Sondag Dr. James D. Smith in memory of Dr. Bill Lawton Patricia M. Worley in memory of Dr. Michael Hellman Dr. & Mrs. Samuel Molind in memory of Dr. Dale Willis
For more information about honorarium and memoriam gifts, please contact stewardship@cmda.org.
MEMBER NEWS
John D. Mellinger, MD, FACS Dr. John Mellinger was named Chairman of the American Board of Surgery (ABS) for the 2020-2021 academic year. The ABS is the certifying body for general surgeons, vascular surgeons, surgical oncologists, pediatric surgeons, and surgical critical care specialists. Dr. Mellinger is the J. Roland Folse Endowed Chair in Surgery, Vice Chair of the Department of Surgery, and Professor and Chair of General Surgery at Southern Illinois University (SIU) School of Medicine in Springfield, Illinois. He received his medical degree from Case Western Reserve University, completed residency training in general surgery at the Blodgett/St. Mary’s Hospitals in Grand Rapids, Michigan and then did a fellowship in surgical endoscopy at Mt. Sinai Medical Center in Cleveland, Ohio. Dr. Mellinger is married to his wife of 37 years, Elaine, and they have four married children and 10 grandchildren. He joined CMDA as a medical student in 1984, and he benefited greatly from the Saline Solution course CMDA offered while he was a young attending surgeon. He has served in a variety of leadership capacities within CMDA, including serving on the Board of Trustees.
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Ministry News
Nathan Dale Willis, DMD Nathan Dale Willis, DMD, went to be with the Lord after a tragic accident on Wednesday, December 23, 2020. Dale graduated from the University of Tennessee in 1983, and then he earned his Doctorate of Dental Surgery from the University of Tennessee Health Science Center in Memphis, Tennessee in 1987. Upon graduation from dental school, Dale was commissioned as an officer in the United States Army. He served honorably as a Captain in the Dental Corps, with postings at Camp Casey, Republic of Korea; Fort Benning, Georgia; and Fort Campbell, Kentucky. After his military service, Dale moved to Bristol, Tennessee, and began his lifelong career as a dentist and eventually as a partner with Alamont Dental Association. Dale and his wife Kristina were married in 1994, and they have three children: Ian, Nathan and Dawson. He was wellknown for service and philanthropy within the local com-
munity, and he was a charter member of Discovery Church where he served as Chairman of Elders. He was a Fellow in the American College of Dentistry; a Fellow in the International College of Dentists; and a Fellow in the Academy of General Dentistry. In 2015, Dale won the Dr. Sig Gruenwald Humanitarian Service Award from the Tennessee Academy of General Dentistry. He has completed numerous medical mission trips to serve others. Dale joined CMDA in 1996, served on the Board of Trustees from 2007 to 2015 and began a new term serving as a trustee in 2019. He also served as a member of the Dental Advisory Council. He played a vital role in the growth and ministry of CMDA in countless areas, and he became a respected voice on our board and served in numerous leadership roles over the years. We are thankful for Dr. Dale Willis and the impact he had in bringing the hope of Christ to the world. He was a servant leader, and he truly exemplified what it means to live a life fully devoted to Christ. Dale’s infectious laugh and joyful attitude will be missed by our entire CMDA family.
GOD LOVES THE WORLD Working with “ Interserve has been
wonderful. I really value the structure that Interserve offers: the chance to be sent by a solid gospelcentered group that helps me think through how we do ministry in a wholistic way.
Speak it. Show it. Live it.
“
Physician, Central Asia
USA
www.interserveusa.org/doctors A SAMPLING OF CURRENT OPPORTUNITIES Surgeon Practice general surgery at a 75-bed hospital serving the region’s tribal people. (South Asia)
Dentist Join two other dentists on staff at a small hospital providing dental care to a rural population. Short or long-term placement. (South Asia)
Medical Students Use your fourth-year med school elective serving and receiving mentored training at a 150-bed rural hospital. (South Asia)
General Practitioner/ Pediatrician Serve local communities and train residents at faith based hospitals. (Multiple opportunities)
Ophthalmologist Help further develop and implement a resident training program for nationals. (Central Asia)
Psychiatrist (Central Asia) Ob/Gyn (South Asia) Otolaryngologist (South Asia)
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CourageTHROUGH theCrisiS Stories from the Frontlines
As our world and our healthcare profession continue to battle the ongoing pandemic, we will not be meeting in person this year. Instead, we invite you to join us for fellowship, encouragement and spiritual renewal at the CMDA Virtual National Convention.
CMDA Virtual National Convention April 29 - May 2, 2021
Register online at
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MEMBERSHIP SURVEY RESULTS
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Jamey Campbell
very five years, CMDA’s Board of Trustees goes through a cycle of comprehensive strategic planning. This wellthought out process has guided and directed the organization throughout the last 25 years, as it focuses on better meeting the needs of our members and providing ministry to those we serve around the world. With the transition of leadership in 2019 to Dr. Mike Chupp as CEO, the board kicked off the process at the January 2020 meeting with training provided by Dale Lefever, PhD, an expert in organizational management who has led hundreds of organizations through the strategic planning exercise. A key part of the strategic planning process has been a wide-ranging membership survey to receive feedback on numerous issues. This survey was originally planned to go out to members in the summer of 2020. And then came COVID-19. Knowing the pandemic was foremost on the minds of our members, as well as people all over the world, we decided to delay the survey until the fall, when we hoped COVID-19 cases would be on a downward trend. As we now know, that was not the case. In order not to delay strategic planning any longer, the board pushed forward with the survey in October 2020. The survey was sent to 14,000 CMDA members across all membership levels, including graduates, residents, students and associate members. In addition to the standard yes/no and ranking questions, open-ended questions were also posed. We received more than 3,500 responses. It will take several months to fully analyze the results, but we wanted to share an early overview of the summary data. Whether you are in the majority or minority on the responses, both are extremely helpful to our board and leadership. The greatest number of responses came from those age 65 or older. The second greatest number of responses came from those between 56 and 65 years of age. A total of 50.6 percent of all member responses came from individuals age 56 or older. This would be in line with the fact that we know the average age of our current members is 55.6. Only 20.6 percent of responses came from members under the age of 36.
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More than half of our members joined CMDA as a student, while 26 percent said they joined after at least five years of practice. This did not surprise us, as we hear story after story of members who credit much of their spiritual growth in their training years to their local CMDA ministry. We continue to see that the least likely time for someone to join CMDA is during residency years, as only 6 percent said they joined then. Fully 81 percent of members said they feel somewhat or very connected to CMDA. CMDA Today (formerly Today’s Christian Doctor) ranked high as a helpful resource for our members. A total of 92 percent found it to be somewhat or very beneficial. In addition to the magazine, 44 percent said they find our various podcasts, such as CMDA Matters, very beneficial. While you continue to find value in our physical resources, the majority of respondents indicated their preferred method to receive resources from CMDA is now through podcast, web-based videos and phone apps. It was evident our members are growing weary of not being able to meet together for fellowship, education and spiritual growth. More than six in 10 found local conferences to be beneficial, while 56 percent indicated the CMDA National Convention is beneficial for them. A total of 64 percent said our continuing education resources, including the new CMDA Learning Center, are beneficial. The responses indicated that email is the preferred method of receiving information from CMDA, followed by CMDA Today. These were followed by our website, podcasts, social media and text messages. Responses also indicated that 30 percent have participated in one of our conferences within the last two years, 24 percent have participated in a local ministry group and 15 percent participated with Women Physicians in Christ (WPC). This is somewhat lower than 2015, when six in 10 participated in a local ministry group and four in 10 had attended a conference in the previous two years. With the restrictions on gatherings and travel for much of 2020, it is understandable why this year’s results were lower. Around the topic of dues, 94 percent of members told us that the benefits and resources available to them as members is appropriate for the level of dues charged.
When asked about CMDA priorities, members told us that the following items should be given “high priority” by the organization: • 76 percent - Development of biblically-based and evidencebacked bioethics position statements • 73 percent - State and federal policy efforts • 67 percent - Healthcare missions/outreach, international • 61 percent - Healthcare missions/outreach, domestic • 38 percent - Regional and national meetings From a policy perspective, our members have strong feelings about the issues they want CMDA to address: • 82 percent - Healthcare right of conscience • 82 percent - Abortion on demand • 78 percent - Physician-assisted suicide and euthanasia • 70 percent - Human trafficking • 66 percent - Sexual orientation and gender issues • 51 percent - Social justice in healthcare We found that 80 percent of our members are either satisfied or very satisfied with their professional careers. As we have seen in previous surveys, this number is somewhat higher among our members compared to the total overall physician career satisfaction rate, which shows that only 71 percent of physicians are “happy” with their careers.1 When asked about spiritual life, 77 percent said, “I consider myself spiritually mature but am still consistently growing.” More than eight in 10 of our members told us they practice Scripture reading and prayer most days or daily. The top concern for our members is the current healthcare system, with 40 percent responding it is a significant area of concern. Somewhat surprisingly, 66 percent indicated they “do not experience any restrictions or difficulties” when asked about their work environment being friendly to people of faith. Another 24 percent said, “I am able to share my faith and follow my conscious but face criticism and opposition.” A total of 10 percent said, “I am restricted from sharing my faith and/or following my conscious in my practice.” A total of 80 percent of our members reported that CMDA helps them integrate their faith into their healthcare practice. One of the new questions in the latest survey was related to racism, reconciliation, equality and diversity. The majority of our members (58 percent) told us they believe CMDA can better support them when it comes to resources and training on how to integrate this timely subject into their life and practice.
SURVEY CONTEST WINNERS Congratulations to Dr. Richard and Cathy Ingle, the winners of an international CMDA trip for two! Because they took the time to fill out the survey and submitted their names for the contest, they were randomly selected to join a future CMDA tour. They will be traveling to Israel on a wonderful two-week tour visiting sites prominent in the Old Testament throughout the Holy Land. (If you would like more information about joining a CMDA tour, visit www.cmda.org/events.) In their words, “We try to live for Christ, trusting in Him to enable us to do so. We joined CMDA about 21 years ago and agree with its stand for Christian ethics and have been encouraged by its publications and conferences. We were so surprised to win this trip. We are looking forward to going to Israel and seeing so many of the places we have read about in God’s Word.” Much more could be, and will be, reported from this survey. The thing most evident across the board is that our members consider CMDA to be an important part of their lives and careers and look forward to our continuing ministry for many years ahead. Please be in prayer for our board and staff, as they develop and implement a new strategic plan that will give direction to how we serve you, our members, over the next few years. Endnotes 1 Saley, C., Chad Saley Chad Saley is a public relations manager at CHG Healthcare, *, N., Levin, R., 28, G., & Says:, G. (2019, March 21). 2019 AAFP/CompHealth Physician Happiness Survey. Retrieved January 07, 2021, from https://comphealth.com/resources/physicianhappiness-survey/
Jamey Campbell serves as CMDA’s Chief Operating Officer. Jamey completed his bachelor’s degree at East Tennessee State University in Communication. In his career, Jamey served in several communications positions including on the staff of Senior Majority Leader Senator Dr. Bill Frist. He began his fundraising career at East Tennessee State University leading the development effort for the Health Sciences Division before joining Precept Ministries International in 2000. Jamey and his wife Janeen live in Elizabethton, Tennessee. They have two daughters and one grandson.
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W
ith millions of COVID-19 vaccine doses already plunged into American arms and hundreds of million more doses on the way, can healthcare professionals confidently receive the vaccines themselves and also recommend them for patients? While responses to this question often involve important emotional factors that need to be addressed, this article focuses on three rational considerations: safety, efficacy and ethics.
Ethical Vaccines Ready for a shot in the arm? Jonathan Imbody, MEd, and Jeffrey J. Barrows, DO, MA (Ethics) 12 | CMDA TODAY | SPRING 2021
SAFETY
The federal government’s revolutionary Operation Warp Speed program produced not just one but several vaccines with breathtaking speed.1 This amazing success put vaccines into arms by December 2020, less than a year since the pandemic broke out. Not so fast, said many Americans—including a surprising number of healthcare professionals. A December 2020 Kaiser Family Foundation poll uncovered a concerning number of American vaccine skeptics, with notably high concentrations in several groups: “Vaccine hesitancy is highest among Republicans (42%), those ages 30-49 (36%), and rural residents (35%). Importantly, 35% of Black adults (a group that has borne a disproportionate burden of the pandemic) say they definitely or probably would not get vaccinated, as do one third of those who say they have been deemed essential workers (33%) and three in ten (29%) of those who work in a health care delivery setting.”2
primarily from two factors: recent scientific advances and the production of vaccines parallel to the testing processes.
Clear explanations for the vaccine hesitancy require drilling down into these responses in greater detail, but a few speculations may help shed some light on the findings. • Republicans, and conservatives in particular, tend to view government programs skeptically, mirroring the thinking of revolutionary forebears who instituted checks and balances on government power. • Adults aged 30 to 49 are more likely than other age groups to have children, and anti-vaccination arguments are salient issues in the parent community, since each parent faces decisions about their children’s vaccination. • Resistance of rural residents might be explained in part by a tendency toward personal independence versus conforming to institutional goals, as demonstrated by choosing to live in greater privacy, away from population and government centers. • Black adults’ hesitancy may reflect perception and recognition of injustices in medical programs, such as the infamous and unethical Tuskegee experiments.
“The speed is a reflection of years of work that went before,” explained Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases (NIAID).3
The vaccine resistance of healthcare professionals, however, seems counterintuitive. Healthcare professionals of all people would be expected to appreciate the risk-benefit advantages of a vaccine compared to contracting disease.
“‘That’s what put us in a position to do this rapidly,’ Graham said in February, before the NIH’s vaccine was first tested in people.”4
However, healthcare professionals also likely would be familiar with the normally long length of time it takes for vaccine testing, production and approval. If a healthcare professional does not realize the factors that allowed Operation Warp Speed to shrink the normal vaccine timetable so dramatically, the shorter time frame may raise suspicions of skirting safety assurance. Combine that suspicion with suspicions of political influence, and vaccine hesitancy predictably results. The unprecedented speed of the COVID vaccines resulted
As outlined in a Los Angeles Times article, “[A] discovery was made in 2013, when [Dr. Barney] Graham, the deputy director of NIH’s Vaccine Research Center, and his colleague Jason McLellan were investigating a decades-old failed vaccine against RSV, a childhood respiratory illness. “They homed in on the right structure for an RSV protein and learned genetic tweaks that stabilized the protein in the correct shape for vaccine development. They went on to apply that lesson to other viruses, including researching a vaccine for MERS, a COVID-19 cousin, although it hadn’t gotten far when the pandemic began.
Besides the pre-existing technological foundation that accelerated COVID-19 vaccine development, the federal government also took an unprecedented, calculated financial risk, by investing billions in vaccine production concurrent with the vaccine trials. By jump-starting vaccine production long before the U.S. Food and Drug Administration (FDA) rendered its judgment, Operation Warp Speed trimmed months off the normal linear vaccine evaluation and production timetable. As a result, the federal government already had millions of doses in store and ready to fly out the door literally hours after www.cmda.org | 13
the FDA announced Emergency Use Authorizations (EUA). The FDA issued an EUA first for the Pfizer-BioNTech vaccine on December 11, 2020 and then for the Moderna vaccine a few days later on December 18, 2020. Both vaccines employ similar messenger RNA technology. The FDA website explains the objective and thorough process involved in an Emergency Use Authorization process:
“I think that likely, based on impact, this will be the greatest medical advance in the last 100 years.”
“From a safety perspective, FDA expects an EUA submission will include all safety data accumulated from phase 1 and 2 studies conducted with the vaccine, with an expectation that phase 3 data will include a median follow-up of at least 2-months (meaning that at least half of vaccine recipients in phase 3 clinical trials have at least 2 months of follow-up) after completion of the full vaccination regimen. “After FDA receives an EUA request, our career scientists and physicians will evaluate all of the information included in the manufacturer’s submission. While FDA’s evaluation is ongoing, we will also schedule a public meeting of our Vaccines and Related Biological Products Advisory Committee, which is made up of external scientific and public health experts from throughout the country. During the meeting, these experts, who are carefully screened for any potential conflicts of interest, will discuss the safety and effectiveness data so that the public and scientific community will have a clear understanding of the data and information that FDA is evaluating to make a decision whether to authorize a COVID-19 vaccine for emergency use. “Following the advisory committee meeting, FDA’s career professional staff will consider the input of the advisory committee members and continue their evaluation of the submission to determine whether the available safety and effectiveness and manufacturing data support an emergency use authorization of the specific COVID-19 vaccine in the United States.”5
In a CNN interview, vaccine manufacturer Pfizer CEO Albert Bourla translated the technical data into powerful words: “I think that likely, based on impact, this will be the greatest medical advance in the last 100 years.”9 Vaccine manufacturer Moderna CEO Stéphane Bancel noted, “We believe that our vaccine will provide a new and powerful tool that may change the course of this pandemic and help prevent severe disease, hospitalizations and death.”10
ETHICS
(Editor’s Note: In November 2020, Public Discourse published a version of the following content on ethical considerations regarding the Pfizer-BioNTech vaccine written by the authors. It is reprinted with permission with changes reflecting the approval of the vaccines.)11
Is Receiving the Pfizer-BioNTech COVID-19 Vaccine Ethical?
The Vaccine Adverse Event Reporting System (VAERS), comanaged by the FDA and the Centers for Disease Control and Prevention (CDC), “continually monitors VAERS reports for any unexpected patterns or changes in rates of adverse events.”6 The CDC is also receiving direct reports from COVID-19 vaccine recipients of any adverse reactions through V-safe, “a smartphone-based tool that uses text messaging and web surveys to provide personalized health check-ins after you receive a COVID-19 vaccination.”7
On November 9, 2020, pharmaceutical giant Pfizer and biotech company and cancer treatment specialist BioNTech stunned the world with the announcement that a “vaccine candidate was found to be more than 90% effective in preventing COVID-19 in participants without evidence of prior SARS-CoV-2 infection in the first interim efficacy analysis.”12 The 90 percent success rate far exceeded experts’ hopes of a 50 to 70 percent effective rate and promised ultimately a potential curb on the global pandemic that has crippled the world’s economy.
EFFICACY
So, what do we know of the vaccine’s ethical considerations, given controversies with some vaccines over the use of cell lines from aborted babies? In brief, the Pfizer-BioNTech vaccine was not developed or produced using any tissue from an aborted child, though it did make use of a biological assessment tool that relies on a cell line (HEK-293) derived from an aborted baby in
Regarding the Moderna and Pfizer-BioNTech vaccines, the CDC noted, “Preliminary data suggest high vaccine efficacy in preventing COVID-19 following receipt of two doses of mRNA COVID-19 vaccine (Pfizer-BioNTech: 95.0% [95% CI: 90.3%, 97.6%]; Moderna: 94.1% [95% CI: 89.3%, 96.8%]).”8 14 | CMDA TODAY | SPRING 2021
below, with cell lines from an aborted baby. The Pfizer-BioNTech vaccine is associated with the HEK-293 cell line, derived from an abortion nearly half a century ago. We agree with Dr. Pacholczyk on the need for government to provide clearly licit options, and we have encouraged the administration to develop morally uncontroversial drugs rather than those tainted by any abortion connection. We do not see quite as clear a definitive divorce of the end user’s acceptance from the drug developer’s actions as Dr. Pacholczyk and Tollefsen suggest. As to future harm, we are convinced of the need to clarify the difference between ethical concession and ethical acceptance, in part to avoid emboldening future abortion-implicated research and development. While agreeing that end users have no direct causal connection to others’ illicit acts, that fact alone is not in our opinion sufficient for arriving at a clear-conscience decision to receive this specific vaccine. Such a conclusion requires weighing relative harms and benefits. 1972. Ethical considerations including loving our neighbor, the unavailability of ethical alternatives and distance in participation and time from the original unethical act make this vaccine a candidate for morally licit use. Let us explain.
Key Principles Can Guide Sound Decision-Making
In a recent Public Discourse essay, Tadeusz Pacholczyk, PhD, examined the ethics and seemingly abortion-endorsing effect of the U.S. government’s “channeling of hundreds of millions of dollars of taxpayer funds directly into the development of COVID-19 vaccines that utilize abortion-derived cells for their production.”13 The apparent concession to abortion-implicated vaccines came at the same time the U.S. Department of Health and Human Services—based on recommendations by an ethics advisory board on which Dr. Pacholczyk served—was putting the kibosh on government funding of fetal tissue research that relies on cell lines from aborted babies. Pacholczyk argued that, while “individual end users have no direct causal connection to those wrongful decisions made previously by others…none of us should have to take drugs that have any connection, even a very remote one, to abortion.” In “Research Using Cells of Illicit Origin and Vaccines from Fetal Tissue,” Christopher Tollefsen anticipated pro-lifers’ dilemma of potential complicity in using a COVID-19 vaccine tied to abortion. He argued, “…it is not cooperation [with evil] strictly speaking; the abortions have already been performed. Nor does any individual pro-lifer’s decision to vaccinate contribute in any meaningful way either to any particular future abortion, or to the work of researchers who insist on using fetal tissue.”14 Operation Warp Speed has funded six vaccine candidates, all of which are associated, though in differing ways as explained
Weighing an indirect user connection concern alongside other ethical considerations is required in the case of the Pfizer-BioNTech vaccine. Several mitigating principles can help assuage the concerns of conscientious end users of drugs that have some connection to abortion: the distance in time from the original abortion to the present use of the drug and the lack of availability of any ethical alternatives.
Ethical Analysis of the Pfizer-BioNTech Vaccine
CMDA has an ethics statement that can help guide individuals’ analyses of immunizations and the potential for moral complicity with evil: 1. “Using technology developed from tissue of an intentionally aborted fetus, but without continuing the cell line from that fetus, may be morally acceptable. 2. “Continued use of a cell line developed from an intentionally aborted fetus poses moral questions and must be decided as a matter of conscience, weighing the clear moral obligation to protect the health of our families and society against the risk of complicity with evil. 3. “Using a vaccine that requires the continued destruction of human life is morally unacceptable.”15 In a recent virtual meeting between faith leaders and government officials leading the charge against the pandemic, Jonathan posed the question this way to Dr. Francis Collins, the director of the National Institutes of Health: “Some have expressed conscience concerns about vaccines that rely on an abortion-derived cell line for production, such as the AstraZeneca–University of Oxford vaccine and the Janssen Research– Johnson & Johnson vaccine. What are your thoughts on these concerns, and how confident are you that at least one vaccine that does not rely on an abortion-derived cell line for production will be available?” www.cmda.org | 15
While the off-the-record meeting precludes direct quotes, we can say Dr. Collins respectfully addressed this concern, highlighting the length of time since the cell lines used in the various Operation Warp Speed vaccines were developed from abortions in 1972 (HEK-293) and 1985 (PER.C6). He referenced the administration’s recent decision not to use NIH funds for certain fetal tissue research. Dr. Collins also invoked the ethical analysis that the use of such a vaccine may be permissible in the absence of any ethical alternative, while suggesting the odds looked good that at least one vaccine of the six U.S.-funded candidates would satisfy pro-life concerns. Is the Pfizer-BioNTech vaccine just such an ethically acceptable vaccine? The answer depends on careful analysis of the vaccine’s implications with respect to abortion. Each of the six COVID-19 vaccine candidates funded under Operation Warp Speed has or is presumed to have had some interaction with a cell line derived from an abortion performed decades earlier. (One company, Sanofi Pasteur, has not yet published documentation that would allow definitive confirmation of abortion-related interaction. The company did recently discontinue its Poliovax polio vaccine, which used the aborted fetal cell line MRC-5.) The absence of any completely untainted ethical choice triggers the ethical principle that in such cases, an individual may in good conscience receive a vaccine in spite of the abortion connection when the good of protecting oneself and others from harm arising from vaccination outweighs the harm arising from the abortion connection. In the case of potentially six vaccines becoming available, we want to choose the vaccine offering the least ethically problematic option.
the Pfizer-BioNTech vaccine used the HEK-293 cell line from a 1972 abortion only to confirm that messenger RNA was properly coding for the spike protein of the SARS-CoV-2 virus. While still ethically disconcerting, the fact that this remote and limited interaction with abortion does not involve the continuing use of an aborted fetal cell line makes it less ethically problematic compared to its competitors that use these cell lines for ongoing vaccine production. Tollefsen offered perhaps the most compelling and easily appreciated consideration for use of an abortion-tainted vaccine: “Refusal to vaccinate oneself and one’s children will not only put oneself and one’s family at risk; it will put others, especially the vulnerable elderly and those suffering from certain chronic illnesses, at significant risk as well.” This consideration goes to the heart of Christian ethics in a way that virtually every believer understands: Vaccinating yourself and those who depend on you is an important component of following the command to love thy neighbor.
What’s Next?
Since portions of this essay were originally published, both Pfizer and Moderna received EUAs through the FDA. Both also made use of a biological assessment tool using the HEK-293
Vaccinating yourself and those who depend on you is an important component of following the command to love thy neighbor.
Deciding which COVID-19 vaccine poses the least ethical concerns hinges in part on the implication of abortion in the initial design of the vaccine, the confirmatory testing of the vaccine and the ongoing production of the vaccine. Vaccines that continue to use the abortion-derived cell line in ongoing production pose the most obvious ethical barrier to use by pro-life individuals. This category includes vaccines by AstraZeneca–University of Oxford and Janssen–Johnson & Johnson. In fact, these vaccines employ abortion-related cell lines in all three stages—design, confirmation and production. The Pfizer-BioNTech vaccine uses a new vaccination platform that injects messenger RNA (mRNA) into muscle cells of the subject. Once incorporated into the cells, they begin to manufacture and release the same spike proteins found on the surface of the SARS-CoV-2 virus. The presence of these spike proteins elicits an immune response within the individual, introducing a new protection from the virus. Unlike the aforementioned COVID-19 vaccine candidates that rely on abortion-derived cells for their ongoing production, 16 | CMDA TODAY | SPRING 2021
cell line, and neither will use a fetal cell line for ongoing manufacture of the vaccine. The next ethical decision is deciding how to distribute the vaccines, given that the initial production was not enough to vaccinate everyone. The Trump administration emphasized a priority of vaccinating first responders and vulnerable populations including the elderly. President Joe Biden’s COVID-19 task force includes Affordable Care Act architect Dr. Ezekiel Emanuel, who in an interview on the Biden administration’s strategy with respect to the virus asserted, “You’re going to see a very different approach here.”16 Besides his staunch opposition to conscience rights in healthcare,17 Dr. Emanuel opined in an essay entitled “Why I Hope to Die at 75” that “living too long is also a loss. It renders many of us, if not disabled, then faltering and declining, a state that may not be worse than death but is nonetheless deprived.”18 Should Dr. Emanuel’s views on aging prevail in the government’s determination of vaccine priority, our challenge may not be simply deciding whether or not the vaccine is ethi-
cally permissible but also whether government officials consider our lives worth preserving. In contrast to Dr. Emanuel, we place high value on the lives of the elderly, and we actually find that consideration a compelling factor in considering whether or not to receive a vaccine with an ethical profile such as the Pfizer-BioNTech vaccine.
CONCLUSION
We recognize that each individual must weigh ethical considerations before making a vaccine decision. When we examine the Pfizer-BioNTech and the Moderna vaccines in light of ethical principles of (a) loving our neighbor by protecting them through our own vaccination, (b) the distance in time from an abortion connection and (c) the fact that the vaccine does not continue to use cell lines derived from an abortion, we find these factors considerable in mitigating the ethical concerns and opening the door to receiving the vaccines in good conscience. If these ethical principles comport with your conscience convictions, and the safety and efficacy evidence prove satisfactory, you can confidently roll up your sleeve for a vaccine shot and encourage patients and friends to do the same. Endnotes 1 h ttps://www.hhs.gov/coronavirus/explaining-operation-warpspeed/index.html 2 h ttps://www.kff.org/coronavirus-covid-19/report/kff-covid-19vaccine-monitor-december-2020/ 3 https://www.latimes.com/world-nation/story/2020-12-07/years-ofresearch-laid-groundwork-for-speedy-covid-19-shots 4 https://www.latimes.com/world-nation/story/2020-12-07/years-ofresearch-laid-groundwork-for-speedy-covid-19-shots 5 h ttps://www.fda.gov/vaccines-blood-biologics/vaccines/ emergency-use-authorization-vaccines-explained 6h ttps://www.fda.gov/vaccines-blood-biologics/vaccine-adverseevents/vaers-overview 7 https://www.cdc.gov/coronavirus/2019-ncov/vaccines/safety/vsafe. html 8h ttps://www.cdc.gov/vaccines/covid-19/info-by-product/clinicalconsiderations.html 9 https://www.cnn.com/2020/11/09/health/pfizer-covid-19-vaccineeffective/index.html 10 h ttps://investors.modernatx.com/news-releases/news-releasedetails/moderna-announces-primary-efficacy-analysis-phase-3cove-study 11 A version of this essay originally appeared at Public Discourse: The Journal of the Witherspoon Institute. Please visit www. thepublicdiscourse.com for more information. It is reprinted in CMDA Today with permission. 12 https://www.pfizer.com/news/press-release/press-release-detail/ pfizer-and-biontech-announce-vaccine-candidate-against 13 https://www.thepublicdiscourse.com/2020/10/72350/ 14 https://www.thepublicdiscourse.com/2020/05/63447/ 15 h ttps://cmda.org/wp-content/uploads/2018/04/Immunization.pdf 16 h ttps://www.usatoday.com/story/news/health/2020/11/08/ president-joe-biden-bring-new-approach-fighting-covidpandemic/6061690002/ 17 h ttps://freedom2care.blogspot.com/search/label/ConscienceEssay 18 https://www.theatlantic.com/magazine/archive/2014/10/why-ihope-to-die-at-75/379329/
Jonathan Imbody, MEd, serves as CMDA’s Director of Federal Government Relations. As CMDA’s liaison with the federal government, he participates in White House events and makes personal contacts with government officials. A veteran writer of more than 40 years, Jonathan authored Faith Steps, which encourages and equips Christians to engage in public policy issues. More than 100 of his commentaries have been published in The Washington Post, USA Today, New York Times, Los Angeles Times, San Francisco Chronicle, Chicago Sun-Times and other national publications. Jonathan received his bachelor’s degree in journalism and speech communications from the Pennsylvania State University, a master’s degree from Penn State in counseling and education and a certificate in biblical and theological studies from the Alliance Theological Seminary in New York. His wife Amy is an author, and they have four children and four grandchildren. Jeffrey J. Barrows, DO, MA (Ethics), serves as CMDA’s Senior Vice President of Bioethics and Public Policy. He is an obstetrician/gynecologist, author, educator, medical ethicist and speaker. He completed his medical degree at the Des Moines College of Osteopathic Medicine and Surgery in 1978 and his residency training in obstetrics and gynecology at Doctors Hospital in Columbus, Ohio. He also completed a master’s in bioethics from Trinity International University in Chicago, Illinois. He dedicated 15 years of his career to fighting against human trafficking within the intersection of trafficking and healthcare, as well as the rehabilitation of survivors of child sex trafficking. In 2008, he founded Gracehaven, an organization assisting victims of domestic minor sex trafficking in Ohio. In 2020, Dr. Barrows published a novel entitled Finding Freedom that realistically portrays child sex trafficking in the U.S.
www.cmda.org | 17
HUMAN TRAFFICKING COMMON PSYCHIATRIC CONSEQUENCES OF HUMAN TRAFFICKING ON CHILDREN AND ADOLESCENTS AND THEIR MEDICAL MANAGEMENT Paul Glaser, MD, PhD, FAAP, and Joyce Lo, MD, FAAP
EARN CONTINUING EDUCATION CREDITS See page 20 18 | CMDA TODAY | SPRING 2021
S
lavery still exists. In fact, modern-day slavery, also known as human trafficking, is more prolific than it has ever been. Trafficking in persons is the recruitment, harboring, transporting, provision and obtaining of human beings for the purpose of commercial sex or labor exploitation. On any given day worldwide, it is estimated that 24.9 million people are victims of human trafficking, 25 percent of which are children.1 In the U.S., it is thought that 400,000 people are currently living in slavery.2 In 2018, 51.6 percent of active criminal human trafficking cases in the U.S. were sex trafficking cases involving only children.3 Obtaining reliable statistics on human trafficking is difficult due to numerous factors, and while we may have some statistics on children in the sex industry, we have little statistical information on minors being exploited in labor. What we do know is that the trafficking of our children happens more often than we may have considered, with many of these children having suffered some years of abuse or trauma before being trafficked. Victims of human trafficking suffer from repeated physical, emotional and psychological trauma, often for years, and sometimes beginning at a young age. Some experience abuse before their trafficking years, which compounds the duration of their mental illness even once they are free of trafficking. Not surprisingly, this causes a plethora of mental health issues. While an emerging body of literature is addressing the mental health outcomes of trafficking, many of these do not account for differences between adults and children. From the studies that are available, it is clear that minors who are trafficked are at high risk for developing post-traumatic stress disorder (PTSD), anxiety and depression. One study researching children in a mental health facility in London reported the most common diagnoses in trafficked children are PTSD (22 percent) and affective disorders (22 percent). The presence of physical violence and sexual violence while being trafficked increased the incidence of substance abuse, suicidal ideation and self-harm. In addition, they found that trafficked children spent a 56 percent longer duration of time in psychological services than their non-trafficked cohorts.4 Other studies have reiterated the high prevalence of PTSD (22 to 27 percent), depression (56 to 57 percent) and anxiety (32 to 33 percent) in children who are survivors of trafficking.5,6,7 One of these studies goes further to describe that 16 percent have suicidal ideation and 9 percent display selfinjurious behavior. A notable 12 percent of the children in their study had attempted suicide within the one month before their interview.7 In addition, the presence of physical violence and/ or sexual violence increased their risks for developing PTSD and depression; threats increased their risk for anxiety.5 Despite these risks, some children will be resilient and show little or no direct mental health consequences after being rescued. Despite the numerous mental health diagnoses that result from human trafficking, treatment of psychiatric diagnoses is not a primary concern. Patients that are newly discovered to be
part of human trafficking will need several basic needs taken care of first. Concerns such as whether a safe placement can be found, proper nutrition, medical needs (sexually transmitted infections, withdrawal) and even if the patient is able to establish a normal sleep pattern will be important to address first. Some patients will defend their abuser or fear retribution if they left their abusive situations. It will still be important to document a mental status exam during the first appointment in order to address any acute psychiatric needs, such as suicidal thoughts or even indifference to rescue. Once the patient is stabilized, then a more thorough assessment of mental health symptoms can be made. Cultural sensitivity will be needed here to understand how the patient will understand their own anxiety, trauma and depressive symptoms. For example, some cultures have learned to express emotional issues with physical health symptoms, such as seeking help for headaches or gastrointestinal problems. Some cultures may have no concept for children and adolescents even having mental health disorders. Screening tests can be used at this stage to assist (see Table 1). If psychiatric diagnoses are uncovered, then referral can be made to mental health services, such as counseling and psychiatric management if they are available in your area of practice. Faith-based services can be engaged at this point if the patient is amenable. The Christian doctrines of forgiveness and a loving God can be essential parts of recovery. In most areas around the world, specialty mental health services are sparse or non-existent. Primary care professionals then may have to utilize whatever counseling services they have in their own clinic, or simply engage and listen, taking care of psychiatric medication needs as they are comfortable.
www.cmda.org | 19
EARN CONTINUING EDUCATION 1.5 HOURS NOW AVAILABLE
e are now offering continuing education credits W through CMDA Today. 1.0 hour of self-instruction is available. To obtain continuing education credit, you must complete the online test at https://www.pathlms.com/cmda/courses/27768. Continuing education for this article is FREE to CMDA members and $40 for non-members. If you have any questions, please contact CMDA’s Department of Continuing Education Office at ce@cmda.org. Review Date: December 23, 2020 Original Release Date: March 1, 2021 Termination Date: February 29, 2024
EDUCATIONAL OBJECTIVES
• Describe the scope of human trafficking in children and adolescents. • Discuss the range of mental health disorders that are commonly found in trafficked people that present in medical settings. • Strategize how to treat trafficked people that is relevant to their clinical setting.
ACCREDITATION
The Christian Medical & Dental Associations is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
PHYSICIAN CREDIT
The Christian Medical & Dental Associations designates this educational activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.
NURSE PRACTITIONER
The American Academy of Nurse Practitioners Certification Program (AANPCP) accepts AMA PRA Category 1 Credit™ from organizations accredited by the ACCME. Individuals are responsible for checking with the AANPCP for further guidelines. Nurse practitioners may receive up to 1.0 credits for completing this activity.
PHYSICIAN ASSISTANT
AAPA accepts certificates of participation for educational activities certified for AMA PRA Category 1 Credit(s)™ by an organization accredited by the ACCME or a recognized state medical society. Physician assistants may receive up to 1.0 credits for completing this activity.
DENTAL CREDIT
CMDA is an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing education programs of this program provider are accepted by AGD for Fellowship, Mastership and membership maintenance credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from 1/1/2018 to 12/31/2022. Provider ID#218742. 1.0 Hours Self Instruction Available. No prior level of skill, knowledge, or experience is required (or suggested).
DISCLOSURE
None of these authors, planners or faculty have relevant financial relationships. Paul Glaser, MD, PhD, FAAP; Joyce Lo, MD, FAAP; Barbara Snapp, CE Administrator; Sharon Whitmer, EdD, MFT; and CE Committee Members. CMDA CE Review Committee John Pierce, MD, Chair; Jeff Amstutz, DDS; Trish Burgess, MD; Stan Cobb, DDS; Jon R. Ewig, DDS; Gary Goforth, MD; Elizabeth Heredia, MD; Curtis High, DDS; Bruce MacFadyen, MD; Dale Michels, MD; Shawn Morehead, MD; Michael O’Callaghan, DDS; and Richard Voet, MD THERE IS NO IN-KIND OR COMMERCIAL SUPPORT FOR THIS ACTIVITY.
20 | CMDA TODAY | SPRING 2021
Although a large database of evidence-based studies does not exist for therapy treatments for children and adolescents who have been through human trafficking, numerous types of therapy have been studied for children with PTSD.8 Trauma Focused – Cognitive Behavioral Therapy (TF-CBT) has a large database for use especially in children. This utilizes a play therapy style that taps into the main way children communicate their emotions—through play. Adolescents respond well to Interpersonal Therapy since they depend on relationships with peers for their emotional well-being. Patients with PTSD may benefit from Eye Movement Desensitization and Reprocessing (EMDR) in which repetitive movements and fluctuating lights are used to help reprogram the brain
trafficking. Most used are the Selective Serotonin Reuptake Inhibitors (SSRIs). Although off-label for most indications in this age group, SSRIs have a long track record of safety and efficacy. They are first line for treatment of anxiety, depression and PTSD for children and adolescents. The main caution is the black box warning for increases in suicidal thoughts, although, thankfully, this is not a common side effect and should not stop professionals from prescribing them. The use of benzodiazepines for anxiety or acute trauma is usually discouraged by child psychiatrists due to the lack of efficacy in long-term use. Insomnia may be treated with melatonin and diphenhydramine. Trazodone is a popular non-addictive sleep aid in teen inpatient units. More recently, prazosin has emerged as a first line therapy for flashback-type nightmares. Suboxone is considered appropriate treatment for some patients who begin to withdraw from opioid abuse after removal from trafficking. A general rule of thumb with all psychiatric medications in children is to start low and go up slowly. A list of helpful medications is given in Table 2. Medications for disruptive mood dysregulation disorder, bipolar disorder and schizophrenia are beyond the scope of this article and usually should be prescribed by a specialist.
while discussing their trauma. Dialectical Behavioral Therapy can be useful if the patient is showing traits of Borderline Personality Disorder (although technically one needs to be 18 years old for an official diagnosis) or non-suicidal self-injury (such as cutting). Since all these therapies take special training to perform, areas of low resources should use basic supportive therapy, utilizing listening, connecting and empathizing as core features. Finally, we need to realize that some patients may destabilize when engaging in trauma-based care, so sensitivity will be needed in deciding when to temporarily stop therapies. In most cases, therapy should be enough to help the patient in their slow recovery from trauma. However, in cases of severe trauma, or when mental illness is prominent in the patient’s genetic background, medications may be helpful. In areas of limited resources, the primary care professional may be the only one who can prescribe medications for the mental health needs of children and adolescents who have been through human
Various barriers can arise in treating children and adolescents of human trafficking with mental health disorders. Patients may be resistant to therapy for fear of retribution from their traffickers. If attachment issues (such as symptoms of Reactive Attachment Disorder) are prominent in your patient, they may seemingly respond well to interventions early on, but as staff and professionals continue to care for them, the patient subconsciously will act out or sabotage treatment, perhaps because they remember being hurt in the past by anyone else who proclaimed they loved them or were trying to help them. Some cultures may be uncomfortable with therapy techniques. Language barriers can also make things difficult. Some patients may be so used to altering the truth to survive that it will be hard for them to tell the truth about trauma. They may invent trauma that did not actually happen in a need to be taken care of and receive attention. Finally, the mental health of your staff and healthcare professionals can present a barrier due to the strain and burnout that come with working with such challenging patients. In conclusion, with human trafficking being prevalent in most countries of the world, healthcare professionals are likely to encounter children and adolescents with mental health issues related to their trauma. Knowing the common diagnoses specific to children and adolescents will help you prepare strategies to implement screening and treatment algorithms for your clinical setting. Use www.cmda.org | 21
of therapy and medications will depend on the resources in your area. Those with limited resources must consider implementing at least the therapy and medications for which they are comfortable. By addressing these critical mental health needs, healthcare professionals can make sure that progress is made in recovery and re-integration. Hopefully with early recognition and treatment, the mental impact of modern-day slavery can be reduced. Table 1
Suggested Mental Health Screenings for Primary Care Settings Depression - Patient Health Questionnaire (PHQ-9) PTSD - PC–PTSD (Primary Care-PTSD) Anxiety - GAD-7 Trauma - Abbreviated PCL-C Bipolar - The Mood Disorder Questionnaire Substance Use Disorders - DAST-10 (Drug Abuse Screen Test) Suicide Risk - SAFE-T (Suicide Assessment Five-Step Evaluation and Triage)
Table 2
Medications for Children and Adolescents
(Most are off-label but commonly used by child psychiatrists)
Depression/Anxiety, PTSD SSRIs
SNRIs
• Fluoxetine (10-40mg daily) • Sertraline (12.5-150mg daily) • Citalopram (10-40mg daily) • Escitalopram (5020mg daily)
• Venlafaxine SR/XR (37.5150mg daily)
Acute Anxiety Buspirone (5-15mg bid prn) Hydroxyzine (12.5-25mg tid prn) Benzodiazepines (usually discouraged except for inpatient settings)
Insomnia Melatonin (1-10mg qhs) Diphenhydramine (12.5-50mg qhs) Trazodone (25-150mg qhs)
PTSD Nightmares Prazosin at bedtime (1-4mg)
Serious Opioid Addiction Suboxone (currently requires certification training in the US)
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Endnotes 1 Global Estimates of Modern Slavery. (2017). International Labor Office, Geneva. 2 National Center for Missing and Exploited Children. https://www. missingkids.org/theissues/trafficking 3 Costa, A. M. UNODC United Nations\Office on Drugs and Crime. Global Report On Trafficking In Persons February 2009 UN. GIFT Global Initiative to Fight Human Trafficking. 4 Ottisova, L., Smith, P., Shetty, H., Stahl, D., Downs, J., & Oram, S. (2018). Psychological consequences of child trafficking: An historical cohort study of trafficked children in contact with secondary mental health services. PLoS one, 13(3), e0192321. 5 Domoney, J., Howard, L. M., Abas, M., Broadbent, M., & Oram, S. (2015). Mental health service responses to human trafficking: a qualitative study of professionals’ experiences of providing care. BMC psychiatry, 15(1), 1-9. 6 Kiss, L., Pocock, N. S., Naisanguansri, V., Suos, S., Dickson, B., Thuy, D., & Dhavan, P. (2015). Health of men, women, and children in post-trafficking services in Cambodia, Thailand, and Vietnam: an observational crosssectional study. The Lancet Global Health, 3(3), e154-e161. 7 Kiss, L., Yun, K., Pocock, N., & Zimmerman, C. (2015). Exploitation, violence, and suicide risk among child and adolescent survivors of human trafficking in the Greater Mekong Subregion. JAMA pediatrics, 169(9), e152278-e152278. 8 Smith, P., Perrin, S., Dalgleish, T., Meiser-Stedman, R., Clark, D. M., & Yule, W. (2013). Treatment of posttraumatic stress disorder in children and adolescents. Current Opinion in Psychiatry, 26(1), 66-72.
Paul Glaser, MD, PhD, FAAP, received a BS/MS in biochemistry from the University of Chicago and his MD/PhD from Washington University in St. Louis, Missouri. He completed the triple board residency in pediatrics, adult psychiatry and child psychiatry at the University of Kentucky. He is still boarded in all three specialties. He is currently a Professor at Washington University in St. Louis and runs the Teen Substance Use Rotation for fellows. He is part of the CMDA Human Trafficking Commission. Through both local clinics and international mission families, he has provided psychiatric care for many children and teens who have been through abuse, neglect and human trafficking. Joyce Lo, MD, FAAP, graduated from George Washington University School of Medicine and completed her pediatric residency at the Children’s National Medical Center in Washington, D.C. She first learned about human trafficking while on a mission trip in Nicaragua. Since then, she has been dedicated to anti-trafficking work and is passionate in educating the medical community about human trafficking. She works with Reclaim13, an anti-trafficking organization specializing in minors who have been sexually exploited. In addition, she participates in the Cook County Human Trafficking Task Force, Healthcare Subcommittee, and she has created the Amazing Grace Human Trafficking Ministry in her church. Most recently, she joined CMDA’s Human Trafficking Commission.
My
CMDA
Story
Jacob R. Morris, MD, serves as a Resident Trustee to CMDA’s Board of Trustees.
“I went into medicine with a desire to follow in the footsteps of Christ, the Great Physician. But medical training has been arduous. I have wrestled with climbing the ladder of academic achievement or merely looking forward to the luxuries that medicine can afford. While these things are not bad in and of themselves, they do not align with my primary calling. CMDA reminds me to keep first things first and wake up every day and live out Christ’s powerful words,
Follow me. CMDA has been an incredible blessing in my life and I am committed to serving with and through CMDA for the rest of my life. After attending the National Convention for the first time in 2015, I was so impacted that I knew I would need to commit to attending every year to ‘breathe life’ into my Christian walk and receive renewed encouragement to live for the kingdom and encourage others.” —Jacob R. Morris, MD
P.O. Box 7500 Bristol, TN 37621 888-230-2637 www.joincmda.org memberservices@cmda.org
JOIN CMDA TODAY You can join Dr. Morris and more than 19,000 healthcare professionals across the country who are part of this growing movement of “Transformed Doctors, Transforming the World.” Visit www.joincmda.org or call 888-230-2637 to join us today.
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FIRST FRIDAYS AT THE MORTONS Dr. Paul and Phyllis Morton
2021
M
y husband and I had just moved from Michigan to Texas for my first year of medical school at the University Health Science Center San Antonio. We walked up to the door of a house we had never visited, hand-in-hand wondering what the evening ahead would hold, with unfamiliar people, in this unfamiliar part of the country. As we arrived at the front door, we could hear the sounds of conversation mixed with laughter inside, along with the delicious aroma of cooking pizza tantalizing our taste buds. Another couple our age greeted us warmly while handing us an apron, sending us toward a buzzing kitchen to begin creating our “couple pizza” for the pizza bake-off contest! Wow! It was a Texas size welcome. We were married this summer after university graduation, now beginning our third month of life together in a brand-new city and state. He has successfully landed a job as computer engineer in a tech company here, while I started my first week of medical school. It’s a 24 | CMDA TODAY | SPRING 2021
long-awaited adventure, finding ourselves on the precipice of sheer joy and terror! The meet and greet event for my first year class introduced us to this evening’s event, “First Fridays at the Mortons.” The fourth year medical student with his wife spotlighted this part of the CMDA ministry with a compelling presentation: “We started coming to the Mortons three years ago. It’s a great place to make friends with other newly married Christian couples while finding resources for our marriage during the struggles of professional school. The Mortons have been hosting First Friday for 15 years, stating their objective is to help couples stay married while offering them a vision for a ministry they could do as professionals. In the midst of our struggles with in-law issues back home, they offered support with wisdom.” So begins another year of our marriage ministry in San Antonio, Texas for married or engaged healthcare couples through CMDA. Every year brings a new class of first year medical/
dental couples, couples just like the one above who come to our home looking for encouragement, for mentoring, for friendship. And along with them comes the return of last year’s second, third and fourth year students. Sometimes healthcare couples also return during residency, especially those we mentored while they were in school. A few times a year, those who are now practicing healthcare professionals will return to our home for a weekend visit. Phone calls, emails and cards keep us connected with many of them even 15 years later. We consider ministering and being involved in the lives of these young couples to be a God-given privilege, as well as a way to give back to the mentors who blessed our marriage the last 45 years. Our own marriage has been enriched and strengthened as we reinforced the biblical truths we learned earlier in our marriage. Interestingly, this ministry has coincided with the marriages of our three daughters, so we had front row seats in observing these young couples within their new marriages. We learned a lot about dos and don’ts!
How We Started
Paul initially discovered CMDA as a medical student in St. Louis, Missouri. He retired from practicing medicine in the U.S. Air Force 25 years later in San Antonio, which happens to have one of the largest CMDA ministries in the U.S. As we began a gynecological private practice, with Phyllis serving as the office manager, God laid on Phyllis’ heart a desire and a need for us to be involved in some ministry together within our community. We began searching and praying over the possibilities, then we were drawn to our local CMDA chapter. We explored the opportunities CMDA offered for Bible study, mission trips, large outreach luncheons and board membership. We knew marriage ministry was our place to land. We reminisced back to our days in medical school and residency by asking ourselves this question: “What had been helpful in our marriage during those challenging days?” A thread of mentorship combined with the fellowship of other Christian couples ran strongly through those years, continuing even to this day. We began discussing the possibility of offering a venue within CMDA’s local ministry to carry on that thread of Christian mentoring and couple fellowship. “First Friday at the Mortons” was birthed, and so our adventure began.
Our Objective and Format
In the last 15 years of ministry, we’ve stayed focused on meeting this objective: “How do we encourage the couples to both stay married and catch a vision for ministry? So how do we meet that goal? Our format for ministry keeps us focused on the goal and offers a baseline for others looking to create this type of ministry in their local CMDA community. 1. Preparation and Facilitation — Start by having a planning meeting in the summer to prepare for the school year.
Create a team from previous active couples and add one or two newcomers from the previous year. Encourage each student couple to select a topic of personal interests to create a plan for facilitating. Facilitation could include involving the group along with another professional couple with abilities to mentor them. This is a natural opportunity to mentor the facilitating couples before their presentation. We try to keep the discussion within an hour and ending with prayers. Student involvement is critical to recruiting, along with your current CMDA chapter’s support. “Evites” are great, but be prepared for some unexpected changes in numbers every time you meet as a group. 2. Topics — If you’ve been married more than 10 years, you won’t have any difficulty coming up with the hot topics of marriage. This is an example of our yearly list: • September: Cheap date nights in the city where they are attending professional school. We like to enhance this topic with the question: “What makes a good date to the husband versus the wife?” • October: In-laws, parents and holidays, which is a timely topic as couples begin planning the holidays with family. • November: Our local ministry sponsors a marriage retreat each November, so our group participates, with that serving as the month’s First Friday meeting. • December: This can be holiday events your city offers, a service project, caroling, games or craft project with couples. • January: Finances, as the money was spent over the holidays. F • ebruary: Sex in marriage, including discussion of what the husband and the wife brought to the marriage. We plan the evening around Valentine’s Day and romance. • March and April: We’ve used a smorgasbord of successwww.cmda.org | 25
ful options in these months, such as communications and conflict; spiritual gifts and ministering together; game night; prescriptions for marital crisis (in which we literally use an old prescription pad with a list). • May: Blessings and celebration for those graduating with wisdom for the future from a panel of residents and practicing healthcare professionals. We stay with the local CMDA chapter’s schedule that takes a break in June and July, with the exception of a one-week mission trip. 3. Day and Timeframe — We learned it was critical to keep the same day and location as much as possible. If we changed the date, inevitably a couple would arrive at our door anyway on the first Friday of the month! So hence the name: “First Friday at the Mortons.” Fridays tend to be a date night for many young couples anyway. Later is a better time with work schedules and traffic. We try to stop at 9:30 p.m. so people who need to work early or study are free to leave. As the host, though, you should be prepared to remain longer. This often becomes a time for deeper discusAND THEN ARRIVED COVID-19 COVID-19 initially stopped the usual modes of our marriage ministry efforts. However, as the weeks went by with no end in sight to the pandemic, the Lord (and phone calls from our couples) began stirring us up to create other approaches. We did three things during the pandemic to continue to encourage student couples. First, we met individually with couples at restaurants that allowed outside dinning. Second, we continued our monthly meetings by using Zoom to meet online, which allowed some residents currently training in other cities to join as well. Third, we followed the guidance from the university to limit groups to a maximum of eight people. In brainstorming with our San Antonio CMDA staff, we landed on the idea to recruit other couples to host three other student couples for dinner. We kept the rhythm of First Fridays and same topics discussed for that evening, but these meetings were occurring at different locations. All the host couples and students reported a positive experience and were happy to consider repeating the format.
However, like the rest of the world, we eagerly wait for vaccination to bring relief as we continue these measures. Some measures may be continued even after the pandemic ends, since new venues offered more involvement for more of our local CMDA council members with marriage mentoring. The negative impact of limited fellowship during COVID-19 birthed creative modes to keep that spark of warmth and community alive. “Not neglecting to meet together, as is the habit of some, but encouraging one another, and all the more as you see the Day drawing near” (Hebrews 10:25, ESV).
26 | CMDA TODAY | SPRING 2021
sion or a couple just wanting to connect with fun. We have been known to be playing board games with coffee until midnight. A monthly schedule works well for connection and cohesiveness. We often meet socially with one of the couples on the team between the scheduled monthly Fridays with an agenda of mentoring. 4. Food — This gathering is not the place for gourmet food, although we have brought in a chef for demonstration while cooking together. We have also found a couple of restaurants with an accommodating venue plus an affordable menu to treat the students in December. Food costs might be negotiable with your local CMDA chapter or as your personal giving to the Lord. Meals that stretch are practical. Students love taking leftovers home, and the couples love to cook some part of a meal together, so be creative! Sometimes other professional couples will come alongside you to help with food preparation, costs and clean up. This is a way for them to be involved but not to have a monthly commitment. Students often offer to help with clean up. Let them!
What We’ve Learned
For others looking to start a local marriage ministry in their area, the following pearls of wisdom were gleaned during our 15 years of ministry. 1. Stay connected to your local CMDA chapter for support and coverage. 2. Develop a core team every year, even if it is only one couple. Add to the team each year with a few of the new couples that demonstrated consistent interest the year before. We do not feel this format would work well with much more that 20 couples. If your group grows that larger, recruit another professional couple to be a second host in their home. 3. Be open to mentoring couples in crisis. Usually, deciding who you should mentor seems to be a chemistry that develops between you, God and the couples. The mentoring often
Know this can be such a critical time to offer this type of ministry to young married couples. The joys and sorrows are deep for them in these tender years. Keeping our healthcare couples married is a worthy investment for our society, along with a legacy in the kingdom of God. Your investment in their marriages with mentorship can reap a high probability of shared joys in your own marriage, as well as the treasure of those friendships for years to come. In short, our marriage and our lives have been immensely blessed by ministering to CMDA healthcare student marriages. And we encourage you to do the same! Dr. Paul Morton is a retired U.S. Air Force OB/ Gyn, who followed his military service by 10 years of private practice, with his wife Phyllis a registered nurse. He currently teaches full-time in the Engineering Department at the University of Texas San Antonio, and Phyllis is a spiritual director. Paul has been on the council of his local CMDA chapter for 15 years. The Mortons celebrated 45 years of marriage in 2020. When their kitchen table is not full of healthcare couples, they love having it filled with their three adult daughters, three sons-in-law, seven grandchildren, extended family or anyone who wants to pull up a chair around the lively family table! centers around the hot topics of marriage, as the couples are looking for more intense support with advice. We try to keep them focused on God and the Scriptures, with some spiritual practices as a couple. Shower them with lots of love, and have fun times with them! When issues hit a crisis level (abuse, separation, significant parent or in-law issues, mental instability of partner), we set the boundary that unless they are receiving counseling, we would not “walk with them in the crisis” as we are not counselors. Unless you are counselors, we encourage you to back away at this point.
Making a Personal Investment
“But I’m so busy I barely have time for anything else, let alone preparing for a group.” “I need to spend what little spare time I have with my own family, not with others.” “My house is not that big, and I don’t have room to host something like this.” “I can’t afford to pay for food each month for a large group of other couples.”
As you read this article, are any thoughts like this running through your head? We understand completely. We’ve been there. These are all barriers we faced and had to overcome. But don’t lose heart!
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MY HOUR
HAS COME! Larry H. Lytle, MD
“Jesus replied, ‘The hour has come for the Son of Man to be glorified.’” —John 12:23
Jesus’ birth, death and resurrection were the fulfillment of multiple Old Testament prophecies, and they coincided with a time period of unbridled harshness and brutality. Death by crucifixion, as described by Martin Hengel, was “a barbaric form of execution of the utmost cruelty” and as “the supreme Roman penalty.”1 It is difficult to have proper gratitude, appreciation and thankfulness for Jesus’ sacrifice without knowing the price that was paid for our salvation. Understanding the death of Jesus is also the key that unlocks our understanding of the character of God. God’s love, God’s holiness, God’s righteousness, God’s justice and God’s judgment are clearly revealed and confirmed by Jesus’ death and resurrection. The reason God cannot “grade on a curve” or accept man’s attempts at reconciliation becomes clear at the cross. In Mark 14, Jesus asked His disciples to wait and pray while he found privacy to seek the Father in prayer. A critical moment having eternal ramifications was at hand. He began to be troubled, “…‘My soul is overwhelmed with sorrow to the point of death…Father,’ he said, ‘everything is possible for you. Take this cup from me. Yet not what I will, but what you will’” (Mark 14:33-36). An angel appeared in order to comfort and 28 | CMDA TODAY | SPRING 2021
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strengthen Him. “And being in anguish, he prayed more earnestly, and his sweat was like drops of blood falling to the ground” (Luke 22:44). Hematohidrosis is a rare disorder characterized by the secretion of blood from intact skin often in association with extreme stress or anxiety. In an attempt to explain the physiological determinants, several mechanisms have been proposed. Most medical explanations involve the sympathetic/parasympathetic nervous system interplay with resulting alterations of constriction and dilatation of blood vessels surrounding the sweat glands. The most significant commonality in all the medically reported cases is the association with extreme mental anguish. Jesus had a full comprehension of the severity of the upcoming scourging and crucifixion. In addition, he had the added mental, psychological and emotional agony, combined with the spiritual burden, of knowing He was to shortly become the focused sin-penalty for the full panoply of humankind’s sin and unrighteousness. Jesus knew that God the Father will soon do something never done before—the Father was going to turn His back on Jesus. After intense scourging, multiple beatings and trauma to His head from thorns, Jesus was led to Calvary for execution. After an agonizing, brutal, cruel, degrading and excruciating death, the soldiers came to Jesus and, upon finding Him dead, thrusted a spear into His side for confirmation. This added traumatic injury left nothing to chance. Greek word order can follow importance rather than strict chronology. Seeing blood would be important in a Jewish context of animal sacrifices, whereas water would be less important. It is likely that the “water” flowed first, representing fluid (effusion) from traumatically induced water in the lung lining as a result of the severity of the scourging and possibly blunt chest trauma from falling on the road to Calvary. The effusion itself could have caused Jesus to have chest pain and shortness of breath. The ensuing blood was likely intra-chamber cardiac blood. In 1968, archaeologist V. Tzaferis excavated a site near Jerusalem called Giv’at ha-Mivtar where a tomb was uncovered. It contained the bones of a man, estimated to be 26 years old, who had died from Roman crucifixion. The bones were found in an ossuary or bone box, that had the victim’s name, Jehohanan, inscribed several times.2 Examination showed that each one of his feet had been nailed to the cross separately and laterally, through the heel bone, and not the front of the foot. There was a nail hole, but no nail, found in the left heel bone. In the right heel bone, a nail was found with the tip bent presumably from hitting a knot in the wood making it impossible to remove the nail without removing the foot, the nail and a piece of wood from the cross all together. There was an indentation on the right radius of the forearm suggesting a nail injury, although 30 | CMDA TODAY | SPRING 2021
this was interpreted differently by later investigators. Also, the bones in the lower legs, both tibia and fibula, had been fractured. Genesis 3:15 says, “And I will put enmity between you and the woman, and between your offspring and hers; he will crush your head, and you will strike his heel.” We now have evidence in this finding of the nail penetrating the heel bone, as to allow for a literal interpretation in addition to the traditional metaphorical one. Few, if any, of the observers would realize that each blow or strike from the hammer represented Satan’s accomplishment and direct fulfillment of prophecy. To the disciples, at the time, it would have appeared hopeless. Within three days, however, the entire passage would be fulfilled. Jesus’ faithfulness, obedience and resurrection crushed Satan’s head! Prior to His death, Jesus said, “…I lay down my life—only to take it up again. No one takes it from me, but I lay it down of my own accord…” ( John 10:17-18). And John 19:30 says, “… Jesus said, ‘It is finished.’ With that, he bowed his head and gave up his spirit.” In Matthew 27:50, it says, “And when Jesus had cried out again in a loud voice, he gave up his spirit.” These verses taken together can be interpreted as either prescriptivistic or descriptivistic. If prescriptivistic, then Jesus made a conscious decision. He determined volitionally to end His life at a certain point when He felt that it was finished (be it pain and suffering finished, or redemption complete, or both). Jesus could say to the Father, “into your hands I entrust my spirit” (Luke 23:46, NASB), because He was supernaturally releasing His spirit and determining the exact timing of His death.
It is clear Jesus had no loss of consciousness but rather retained full mentation and cognition up to the point of death. This would be highly unlikely in either exhaustion asphyxia or severe hypovolemic shock as a cause of death where mental obtundation prior to death is the rule. He likely experienced a sense of impending doom a few seconds or minutes before His death, allowing Him to cry out and make several brief statements. A consideration of all the data points in Jesus’ death would suggest He died of a sudden acute cardiac event (probably ventricular tachycardia) in the face of severe trauma complicated by physical exhaustion (but not exhaustion asphyxia) and hypovolemia (but not severe shock.)
Conclusion
Jesus’ faithfulness is the evidence of EASTER.
If descriptivistic, however, the utterances describe what Jesus felt in that moment. He sensed and knew that something catastrophic was occurring internally. Something that felt like death was imminent, and the reason He might have known this could be explained by the phenomenon of impending doom. This phenomenon can occur in individuals immediately prior to death in certain clinical situations, including heart arrhythmias and heart attacks. Jesus was fully man and fully God, but He chose to voluntarily limit and not use His powers of deity outside of what was clearly the direct will of the Father. This voluntary and temporary non-use of, or limitation of, divine power is described in the second chapter of Philippians as an emptying of Himself by assuming the form of a slave and taking on the likeness of men. His life showed that He never used His special power of deity to tend to His own pain, personal gain, comfort, convenience or safety, but rather He used it for teaching others, showing compassion and obeying the Father. Therefore, a natural process of death where Jesus sensed the end but didn’t interfere to define the moment of death seems reasonable. Jesus didn’t make the decision as to when the full price of the sin penalty was paid, but rather He deferred to the Father. Jesus spent His entire life deferring to the will of the Father, and the decision concerning the exact moment of His death was likely included in that spectrum. Numerous healthcare professionals have offered explanations as to the actual cause of Jesus’ death. They include the following: cardiac rupture, cardiac tamponade, myocardial infarction, exhaustion asphyxia, hypovolemic shock, non-hemorrhagic shock, traumatic shock, pulmonary embolism, coagulopathy, acidosis and electrolyte imbalance. Lloyd Davies, among others, has advanced the idea that Jesus did not actually die on the cross.3 What all the “swoon theories” seem to have in common, though, is a penchant for historical revisionism, a vivid imagination and unrestrained medical speculation.
Enormous price paid! Atonement accomplished! Salvation secured! The value of the gift—indescribable! Eternal blessings! Resurrection certain! Table 1
A representative selection of medical hypotheses for the cause of death of Jesus, or crucifixion in general.
Cause of Death
Background of Author
Cardiac rupture
Physician
Heart failure
Physician
Hypovolemic shock
Forensic pathologist
Syncope
Surgeon
Acidosis
Physician
Asphyxia
Surgeon
Arrhythmia plus asphyxia
Pathologist
Pulmonary embolism
Hematologist
Voluntary surrender of life
Physician
Didn’t actually die
Physician
Endnotes 1 Hengel, Martin Crucifixion in the Ancient World and the Folly of the Message of the Cross. London and Fortress Press, 1977 2 Hass, N. “Anthropological Observations on the Skeletal Remains from Giv’at ha-Mitvar.” Israel Exploration Journal 20 (1970), 38-59 3 Lloyd-Davies, M, Lloyd-Davies TA, “Resurrection or Resuscitation?” J R Coll Physicians Lond 1991 Apr;25(2):163-170
Larry H. Lytle, MD, is a graduate of the Ohio State College of Medicine. He completed his internal medicine residency at Riverside Methodist Hospital in Columbus, Ohio. He is the founder of Worthington Medical Center and has served as the area director for the Columbus/Central Ohio chapter of CMDA.
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Bioethics The Dr. John Patrick Bioethics Column
SEEING THE BIG PICTURE OF John Patrick, MD
I
like history, and so I don’t like bioethics. Why? Because I consider it to be a deceptive word used to make people feel good when they should be afraid. And because it took medical ethics out of its privileged position of being solely concerned with the only creature made in the image of God and secularized it. When CMDA asked me to begin writing a regular column on bioethics, which could also involve input from my colleagues and friends, I accepted the challenge. This column is therefore designed to lay a foundation for what I hope will ensue—a lot of reading and some worthwhile discussion in the hospital lounge or the office breakroom. 32 | CMDA TODAY | SPRING 2021
I began medical school in Britain in the late 1950s. At that time, there were no ethics lectures. This, I hasten to add, did not mean there was no unethical behavior; instead, it meant there was simply an expectation that we would become “gentlemen.” British hypocrisy! However, there was also a degree of realism about it. We are all enculturated into medicine; therefore, it changes us, because we cannot avoid being aware of what a great privilege it is to be a healthcare professional and to see both the pathos and the nobility that illness can draw out of ordinary people. Interestingly enough it was not in medical school or university where I saw the most reliable (ethical) behavior, but it was much
earlier in my life. I grew up in a blue-collar industrial community where doors were not locked, women were not afraid to walk down the street alone and divorce was exceedingly rare. It was a community because it had a shared story of how we should behave, which was not thought of as the consequence of history. Indeed, it was not thought about at all. It was simply who we were. Ethics were caught, not taught. The first of Wendell Berry’s Port William novels illustrates my point beautifully. The novel describes the lives of rural America 100 years ago when America was, in the words of Alexis de Tocqueville, “a country with the soul of a church.” The Bible made America. Bioethics, on the other hand, was created (not maliciously) to push healthcare professionals out of discussions about ethics by professionalizing it, thus providing work and employment for philosophers. Programs were created that made some doctors into amateur ethicists taught by philosophers. Sadly, many of them have largely become the lapdogs of power used to legitimize bad behavior. Pace! I still trust a few of them, but when did you last say that a standard model hospital ethicist had made you wise? Paul’s ethics, however, are interesting, and they are wise. His letters were largely written to deal with church misbehavior, and he thought the solution was a few pages of theology and a couple of sentences of “ethics,” usually something like “love your spouse and children,” “pay your workers promptly,” etc. It would be hard to put an ethics course together if that were the only content, but Paul was Jewish, so he knew that the Torah makes Jews and disobedience makes tragedy. Only if you are biblically literate and can remind your pupils of the reality of sin, righteousness and judgment with historical illustrations can you have ethics that make existential sense. The secular ethicist, who believes that Darwin got it right and that we are merely highly evolved animals, can’t do that. And the secular ethicist can’t answer the question, “Why should I obey pre-Darwinian norms?” Clearly this deserves an article in its own right. So, one of the future columns will be about why ethics lectures cannot make you ethical and what actually does make you ethical. Nowadays, most Christians are not terribly good at defending their faith. We are on the defensive. The key to changing this is to learn the art of questioning. When confronted with behaviors the Bible condemns, we don’t need to blurt out, “That’s wrong!” Rather, we need to ask, “What are you presuming to get to that conclusion?” Jesus asked wonderful questions and answered questions with wonderful stories, which put the ball firmly in the opposition’s court. The best modern introduction to this art form I know of is Peter Kreeft’s books of dialogues, especially The Best Things in Life and A Refutation of Moral Relativism. Raising questions and pointing out the best answers will be a motif of this regular column in CMDA Today. I intend to introduce you to many of my friends and colleagues by asking them to contribute columns that include their best questions.
History matters. The history of how science shook off the shackles of Aristotelian science also played a role in how we in the Anglosphere developed a significantly different approach to ethics from that of the Europeans. Thus, one of the columns will be “1277 and all that,” which will lead us to Merton College Oxford and William of Ockham, and thence via Paris and via René Descartes and via Francis Bacon to the scientific explosion of the 17th century, where science took over the word “fact” for what it does and moral facts became personal opinions. These changes are not unrelated to the reformation and the religious thought of Johannes von Helmont and Robert Boyle. Science was not at war with faith, but rather it was dependent on what faith had produced, and in the intoxication of its success, it forgot its parents. Modern science is necessarily reductionistic. I believe that is the right way to do science, but it is not the right way to do life. Once one sees this, it becomes much easier to challenge the modern world. In the 17th century, most major scientists accepted the Christian position that we were created by God. The humanities, which really took off with the so-called renaissance, were stimulated by the rediscovery of classical art and literature. With the French philosophes of the 18th century, the humanities became dismissive of the faith of ordinary people. What happened? What were the differences between them that led to a hugely successful science and the rest of the university now mired in multiple studies programs which have spawned all the “isms?” There is no agreement among academicians, but some facts are undeniable. For science, systematic experimentation and the consequences of the printing press are certainly major factors. Centuries of trying to work from first premises had not achieved anything like the new obsession with measurement. Quantification replaced the ancient world of qualities, and the scientific world flourished. But “physics-envy” programs in the social sciences lost their roots in the real scholarship of philosophy, theology, languages and history. Only with a big picture can we see why autonomy, justice, beneficence and non-maleficence must be placed in context and their hierarchy understood. In my view, God’s gift of the Torah is essentially based on a clear account of what God will not tolerate. This can be extended to doing good, which makes justice authoritative, and which makes freedom the power to do what we ought, not the license to do what we want. John Patrick, MD, studied medicine at Kings College, London and St. George’s Hospital, London in the United Kingdom. He has held appointments in Britain, the West Indies and Canada. At the University of Ottawa, Dr. Patrick was Associate Professor in Clinical Nutrition in the Department of Biochemistry and Pediatrics for 20 years. Today he speaks to Christian and secular groups around the world, communicating effectively on medical ethics, culture, public policy and the integration of faith and science.
www.cmda.org | 33
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