Editorial
by David Stevens, MD, MA (Ethics) — Chief Executive Officer
Basic Training I love basketball! Yes, I was raised in Kentucky and “bleed blue” for the Wildcats. I grew up when Adolph Rupp was the coach and “our team” always seemed to win. I still remember that momentous day when dad, traveling back from a preaching engagement, was seated next to the “Coach” himself on the plane. He talked about it for weeks and even made a pretty good sermon illustration out of it! Coach Rupp could take a good basketball player and make him a great one. He could take a great ball handler and make them even better. He did that by continually working on the basics. At first new players didn’t see the need for it. They had been playing basketball for years. They were “Mr. Basketball” in their state. Weren’t they a scholarship player at one of the most prestigious programs in the country? It was obvious to them that they were going to be a college star and end up in the NBA. But Coach Rupp knew you couldn’t get better till you knew how bad you really were, so just like in Army basic training, he first tore each player down before he began building them back up. He broke down every aspect of their dribbling so he could teach them to dribble better. He critiqued their jump shot, their lay up, and their foul shooting. He then taught them the basics all over again. He did the same thing when players would go into a slump. For some unexplained reason, their shots weren’t landing, they were committing too many fouls, or they were turning the ball over for no reason. Coach knew it was time to get them back to the basics.
You are a lot like one of those basketball players. You have gotten so busy trying to win the game that you are playing today, that you miss the opportunity to go from good to great. You want to learn a new surgical technique, understand a new miracle drug, or just get your patient list finished on time, when the real issue is that your compassion is sloppy or your communication skills are not up to par. Or perhaps you are working hard but find yourself in a slump. You realize you are driving your health team instead of leading them. Or you have gotten way out of balance trying to care for everyone else’s needs that your care for yourself has suffered. Or you have short-changed your family in relation to your time and love. Or worst of all, you have disconnected from God and are trying to run your life with just the power of your own abilities. Others may still see you as a “star,” but deep down inside, you know that something is wrong and getting worse. So it is time to get back to basics. We have lined up a great set of “coaches” in this issue to help break it down for you. They will help you learn where you are so you can begin to get back to what God designed you to be. They will give you insights and practical tips based on their experience. It is going to be incredible training, so go to the locker room in your mind, put on your training outfit, and listen up as you turn and read the following pages. Then practice what you are taught. If you do, you will not only get back your old form, but also be better than you ever have been at what God has called you to be. ✝
CMDA FORUM An opportunity for you to share your comments and questions, hosted by CEO, Dr. David Stevens.
The recorded answers will be posted on our website on January 24. CMDA members will be notified by e-mail as a reminder to listen.
Between January 1-15, 2011 you will have the opportunity to leave a message on our Hotline with your comments or questions. We will respond to as many appropriate questions as possible.
CMDA HOTLINE: 423-844-1072
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contents Today’s Christian Doctor
VOLUME 41, NO. 4
The cover art “Chief of the Medical Staff” is by Nathan Greene, courtesy of the Hart Research Center (www.hartresearch.org)
Winter 2010
The Christian Medical & Dental Associations® – Changing Hearts in Healthcare – since 1931.
12 How Shall We Then Practice? by Farr A. Curlin, MD
Knowing why you do what you do is the key to doing it well
19 Communication: The Need to be Understood
26 More Standing Orders for the Christian Medical Student by Ronald L. Machado, MD
Part two of Dr. Machado's continuing effort to equip Christian medical students for the journey ahead
29 Kay Kerosene
by Allan M. Josephson, MD
by Ashley C. McGee, MD
A significant part of providing optimal care involves establishing good communication with your patients
An illustration of how easy it is to treat patients with less respect than they deserve
22 The Providence of the COMFORT: Letters from Haiti
30 Bioethics Series Informed Consent
by Nick Yates, MD, MA (Bioethics)
by Clydette Powell, MD, MPH, FAAP
One doctor’s letters home while providing medical relief following the quake in Haiti
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Progress Notes Advertising Section
Regional Ministries
EDITORIAL COMMITTEE
Gregg Albers, MD Elizabeth Buchinsky, MD John Crouch, MD William C. Forbes, DDS Curtis E. Harris, MD, JD
Rebecca Klint-Townsend, MD George Gonzalez, MD Samuel E. Molind, DMD Robert D. Orr, MD Richard A. Swenson, MD
VICE PRESIDENT FOR COMMUNICATIONS
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Pulp CMDA is a member of the Evangelical Council for Financial Accountability (ECFA). TODAY’S CHRISTIAN DOCTOR®, registered with the US Patent and Trademark Office. ISSN 0009-546X, Winter 2010 Volume XLI, No. 4. 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 © 2010, 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,Tenn. Postmaster: Send address changes to: Christian Medical & Dental Associations, P.O. Box 7500, Bristol, TN 37621-7500. Undesignated Scripture references are taken from the New American Standard Bible. Copyright© 1960, 1962, 1963, 1968, 1971, 1972, 1973, 1975, 1977 by the Lockman Foundation. Used by permission. Scripture references marked (KJV) are taken from King James Version. Scripture references marked Living Bible are from The Living Bible© 1971, Tyndale House Publishers. All rights reserved. Scripture references marked (NIV) are from the Holy Bible, New International Version®. Copyright© 1973, 1978, 1984 by the International Bible Society. Used by permission. All rights reserved. Other versions used are noted in the text.
For membership information, contact the Christian Medical & Dental Associations at: P.O. Box 7500, Bristol, TN 37621-7500; Telephone: 423-844-1000, or toll-free, 1-888-230-2637; Fax: 423-844-1005; E-mail: memberservices@cmda.org; Website: http://www.joincmda.org. 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.
Dr. Woods Receives Mayo Humanitarian Award John Woods, MD, PhD, was awarded the 2009 Mayo Clinic Alumni Association Humanitarian Award for his lifelong dedication and tireless devotion to helping vulnerable people in the clinic, the community, and around the world. Dr. Woods grew up in Beijing, China, where his parents were missionaries. He says the context of his life has been as a person of faith. He volunteers for humanitarian efforts in the community; is the co-founder and chair of HELP (hunger elimination program); is a board member, chair, and volunteer physician for Season Hospice in Rochester, Minn.; and he is co-founder and chair of the Rochester Medical Relief Mission Group. He has volunteered for short-term surgical groups in underserved areas around the world. Dr. Woods joined the medical staff at Mayo Clinic in 1969 as a consultant in Plastic Surgery and coordinator of the Mayo Clinic Organ and Tissue Transplant Program. Dr. Wood received the Distinguished Mayo Clinician Award in 1991 and the Mayo Clinic Distinguished Alumni Award in 1999. He has been a member of CMDA since 1953.
S. Hughes Melton, MD, Named AAFPs 2011 Family Physician of the Year The American Academy of Family Physicians has named S. Hughes Melton, MD, FAAFP, the 2011 Family Physician of the Year. The award honors one outstanding American family physician who provides patients with compassionate and comprehensive care, and serves as a role model professionally and personally in his or her community, to other health professionals, and to residents and medical students. In July 2000, Melton co-founded C-Health in Russell County, Va., with practice partner Brian Easton, MD, FAAFP, making a long-term commitment to improving the health and lives of people in rural southwest Virginia. They began by providing full-spectrum family medicine services including obstetrical, pediatric, geriatric, inpatient, and outpatient care. Recognizing that his community had a substance abuse epidemic, Melton became an expert in primary care treatment of addiction and chronic pain and opened the first buprenorphine treatment program in the region for outpatient treatment of opiate dependence. He also serves as a consultant to other providers in the region. Melton’s physician-led, interdisciplinary team ensures patients have access to the care they need, when they need it, regardless of their ability to pay. Photo by LBJ Images
EDITOR
David B. Biebel, DMin
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Melton’s call to service can be seen in C-Health’s “practice tithe fund.” The clinic puts aside a portion of its profits to help needy community members pay their electric and fuel bills and cover the cost of food, shelter, or medication. The tithe also supports mission partners in El Salvador. C-Health has chartered a foundation to manage the fund as well as fundraise for college scholarships and other community needs. As a result of C-Health’s successful efforts to recruit physicians, mid-level providers, clinical pharmacists, and counselors to the practice, Russell County is no longer considered to be medically underserved. Dr. Melton has been a member of CMDA since 1990. Some information in this article was adapted from the AAFP release at: http://www.aafp.org/online/en/home/media/releases/2010b/fpoy-melton.html
2011 CMDE Conference Scheduled for Thailand
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Registration is now open for the CMDA Continuing Medical & Dental Education (CMDA-CMDE) Conference XXXI to be held in Thailand, Monday, February 14 – Thursday, February 24, 2011. It is for physicians, dentists and public health professionals serving in agencies/
institutions/clinics outside of North America. Other health care professionals will be allowed to register on a space available basis, but they must be living and serving overseas. Families are welcome at this conference and a children’s program will be provided. The conference will be held at Suan Bua Resort, Chiang Mai, Thailand. The educational goal of CMDE is to provide state-ofthe-art updating and review of modern medicine. The following will be offered: • Approximately 115 hours of lectures from which one can get approximately 50 hours of Category 1 credit for physicians and approximately 35 hours continuing dental education credit • Basic Life Support (BLS), Pediatric Advanced Life Support (PALS), Advanced Cardiac Life Support (ACLS), Advanced Life Support in Obstetrics (ALSO), Neonatal Resuscitation Program (NRP), Ultrasound course, Diabetes course The mission of the CMDA CMDE Commission (which runs this conference) is to provide CMDE in a compact, multiple track model enabling medical and dental people serving overseas to affordably earn Category 1 CMDE credits (American Medical Association and Academy of General Dentistry) to assist in maintaining licensure in the USA. If you are serving overseas and would like more information, e-mail Donnie Luper, DDS, at: lupercmda@ suddenlink.net.
CMDA Regional
teaching in foreign medical/dental schools, and nursing. You can learn more at: www.cmda.org/discoverthejoy. Registration is $25 for students and $50 for professionals in practice.
Marriage Enrichment Mission Conference Come spend an exciting day with us at our second annual “Discover the Joy” mission conference, February 5, 2011 at Grace Fellowship Church in Johnson City, Tenn. Hear the stories and challenges of Dr. Russ White, missionary thoracic surgeon in Kenya, E. Africa, and of Dr. Rebecca Naylor, surgeon in India. They will be joined by Rev. Bert Jones, CEO of Go International and Steve Noblett, CEO of Christian Community Health Fellowship. Three break-out sessions throughout the day will give you a chance to hear practical advice and opportunities of local and regional ministries as well as from around the world. There will be special sessions for medical residents, audiologists, those interested in short-term service, long-term service, service within the United States,
The Marriage Enrichment Ministry was started by members who saw a need to minister to married medical and dental professionals. This ministry offers six to eight conferences per year to provide medical and dental couples with an opportunity to nurture and grow in their marital relationship. The conferences are led by CMDA members of the Marriage Commission and CMDA theologically trained field staff. The conferences have a three-fold format consisting of brief information sessions, private time for couples to work on assignments to assess their marital relationship, and small group sessions which address the unique needs and stresses of medical/dental marriages. The next conference is February 18-20, 2011, in Clearwater Beach, FL, at the Sheraton Sand Key Resort. To register go to Master Event Calendar on the CMDA website.
Every leader needs to be held accountable. If you are not responsible to someone you soon will be irresponsible with everyone. Your leadership heritage is measured by how well things would move ahead if you dropped dead tomorrow.
Leadership Proverbs
Reinforce each team member’s identity and uniqueness. Knowing you are significant motivates by David Stevens, MD, MA (Ethics) extraordinary performance. and Bert Jones If you create a sense of family, your team members will not want to leave home.
A proverb is a short saying that expresses a truth and offers advice to the reader often with an element of wit. In Leadership Proverbs, David Stevens, MD, MA (Ethics) and Bert Jones have condensed the knowledge contained in thousands of leadership books into potent principles. Like a diamond focusing light, these proverbs cut through the verbosity and provide a treasure trove of guidance gems. True leaders are magnetic. They attract followers and seemingly effortlessly affect other people’s thinking and actions through their expressions, examples, and force of personality. Simply put, leadership is the ability to influence other people. A few people are born leaders, but anyone can be trained to lead by learning to adhere to leadership principles. Leadership Proverbs has a leather-like binding and comes in a beautiful presentation box. $16.99
Available from CMDA Life & Health Resources: 888-231-2637 or www.shopcmda.org
I love this new book. Wisdom flows throughout the hundreds of uplifting thought provoking sayings. Let the wisdom of this book help you become the leader God is calling you to be. Every Christian leader should have this book on his or her desk. ~ Frank Lofaro, CEO, Christian Leadership Alliance
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from the
CMDA
President
George Gonzalez, MD
Back to Spiritual Basics – Part 2 Recently, my heart has been heavy over the things that I believe grieve our Lord. I agree with G.K. Chesterton. When asked by a newspaper columnist, “What’s wrong with our world?” Chesterton wrote a brief letter with this response. “Dear Sirs: I am. Sincerely, G.K. Chesterton.” Yet, he failed to give a solution to our dilemma of sin. As I have become more aware and witnessed firsthand the vulgar atrocities of man in human sex trafficking, as I took care of victims as young as nine years old in Nicaragua, I came to see how vile and evil is Satan’s influence in the heart of man. As I recently witnessed the suicide death of a friend, pastor, and patient who believed the lie from Satan that he was better off dead, I was angered that we could be so influenced by things of this world. As I have witnessed multiple Christian marriages break up out of infidelity or “incompatibility,” I weep that we as a Christian community have succumbed to the world’s standards and ways. What we really are doing is doubting God — that He knows what is best for us. We also doubt His authority and lordship in our lives. When we go directly against His written Word, we dishonor the sovereign King. What is the answer to our dilemma? I believe it’s to realize that we have forgotten our first love and focused on the world. We can be like Eve who was deceived by the devil’s temptations of pleasure and power, or like Balaam who sold his soul for profit. But there always is a consequence when we choose other than complete obedience and submission to His will — ultimately, death and separation from Him.
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I tell young people that our choices determine our destiny — so choose wisely. Know for certain that God desires your best because He is a good and loving Father. He has shown us the way of life . . . why do we choose the path apart from Him? We, like Eve, doubt God and choose forbidden pleasures. Our problem as the Body of Christ is being unable to remain focused on God and His way, desiring to please Him in all we do. So how do we make it right? 1. Surrender your life again fully to Christ (James 4:7-10). 2. Acknowledge His goodness and forgiveness (Psalms 51). 3. Recognize that you have been bought and ransomed by the blood of Christ (Gal. 2: 20; 1 Cor. 6:20 and 7:20). 4. Read, memorize, and meditate upon His Word daily in order to be set free from any lies, bondages, or temptations of the world (Psalm 119:9-11; Psalm 1). 5. Pray for a transformed heart to continually desire to please Him as a son wants to please his loving Father (Romans 12:2; Proverbs 10:1). 6. Openly witness of His goodness in order to bring people closer to Him (Matt. 5:16). 7. Keep accountable with a small group of prayer partners (Eph. 6:18-19, Heb. 10:2425, and Psalm 133). I am proud of the leadership and example of most of the CMDA members I know. But we, too, are vulnerable, especially when we think we‘re not. Knowing the devil’s scheme — let us stand firm then (Ephesians 6:14). ✝
Medical Education International (MEI) FOR INFORMATION ABOUT MEI OPPORTUNITIES, VISIT:
WWW. CMDA . ORG / MEI
God is Using MEI
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In June, MEI completed an outstanding fiscal year of service to international colleagues by sending fifteen teams to eleven nations, most to the Muslim and Buddhist world. Dr. Larry Norton, right, received this Teams taught in gift on behalf of the Mongolian many specialized Good Acts Society, their CMDA. areas of medicine and surgery. Among them were pediatric rehabilitation, palliative care, cleft palate surgery, many topics in surgical subspecialties, bioethics, and even faculty development! Dr. Larry Norton, a veteran of many MEI teams, and part of the MEI
Mongolia Project, was selected at CMDA Teacher of the Year and recognized at the CMDA National Conference. In April, MEI learned that Mrs. Marian Schindler had gone to be with the Lord. Marian and her husband Dr. Bob Schindler co-founded MEI’s predecessor organization, the Commission on International Medical Educational Affairs (COIMEA). Though sad for her family’s loss and although we will miss her joyful and encouraging personality, we are confident both she and Bob are glad to be reunited! The Schindler family welcomes memorial gifts to MEI in their honor. MEI’s fall 2010 teams are off to a great start. So far teams to China, Mongolia, Egypt, and Kosovo have been completed and teams to Kenya, Central Asia, the Middle East, Azerbaijan, and Korea are planned before the New Year. God is at work in and through MEI! If God has gifted you in teaching, contact MEI to see how you can participate.
Global Health Outreach (GHO) FOR INFORMATION ABOUT GHO OPPORTUNITIES, VISIT:
WWW. CMDA . ORG /GHO
GHO – A Fulcrum for the Gospel by Don Thompson, MD, MPH, TM
Photos courtesy of CMDA’s Digital Media Center
Director, Global Health Outreach
It’s easy to demonstrate Christ’s love in person through a short-term mission with GHO.
The Christian Medical & Dental Associations continue to develop new opportunities for members to be good stewards of their medical skills. Not only should each of us respond to our Savior’s call in Matthew 25 to serve others — particularly “the least of these” — as if we were serving Him, we should mercifully care for widows, orphans, and other victims of injustice. Global Health Outreach (GHO) provides many settings for you to use your skills while being a Great Commission disciple maker. Medical and dental personnel have a great challenge when trying to find opportunities to serve for relatively short periods of time. You desire to use your skills wisely in serving the most needy, but you are looking for the right way to meet emotional and spiritual needs as well. You realize that the medical care that is provided on most shortterm missions has a limited impact, so you want to partner with others who are able to build on your medical work to meet long-term needs — in community develop-
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ment, with vocational training, but most importantly in meeting the spiritual needs of these people whom our Lord says that He loves. He tells you to serve them as if you were serving Him, and you want to obey! What better way than introducing them to our Lord Jesus Christ? No matter where you are along the continuum in your training or practice of medicine, dentistry, nursing, pharmacy, or any other allied health profession, or in any other career, you are commanded by our Lord to make disciples. Our team leaders are focused like a laser on you and your spiritual growth as you further develop your sense of purpose on a short-term medical missions trip with Global Health Outreach. You will learn more about engaging with different groups, and our national partners will help you clarify your vision of the opportunities that exist as you serve others. Many of our team members bring along family members, and find that they strengthen their family bonds and lay down permanent memories as they benevolently work on behalf of others. Archimedes said, “Give me a lever long enough and a fulcrum on which to place it, and I shall move the world.” Global Health Outreach seeks to serve you as your fulcrum. When you place the lever of your medical and dental skills against the GHO fulcrum of quality short-term medical missions, experienced team leaders, and tested national partners, you cooperate with the power of the Holy Spirit to enable the truth of the gospel of Christ to be shared with
thousands of people each year. God is being glorified as many hear of His love and mercy and turn to Him!
GHO missions provide many opportunities to provide care to those who might not otherwise receive it.
Preparing for the Future!
An Orientation for Medical Missions April 15 – 17, 2011 CMDA Conference Center at the National Headquarters in Bristol, Tennessee Content extremely valuable for both participant and spouse. Faculty • David Stevens, MD, MA (Ethics) • Gene Rudd, MD • Susan Carter, BSN, MPH • Daniel Tolan, MD and other guest facilitators! For more information and to register go to: www.cmda.org/orientationformedicalmissions
How Shall We Then Practice? Medicine as
,
by Farr A. Curlin, MD
, and Christian
.
Editor’s Note: This article was originally published in the journal Health & Development, published by the Christian Community Health Fellowship (CCHF), information about which can be found at: www.cchf.org.
An in-depth analysis of the proper foundations for truly Christian practice
W
hat is medicine? Is it a science? Is it a profession? Is it an industry? What has the Christian tradition to say about medicine? And does what the Christian tradition says really matter in the end? In hopes of beginning to address these questions, this essay explores three Christian metaphors which apply to the practice of medicine, namely medicine as gift, medicine as power, and medicine as vocation. For each metaphor, I will attempt to identify errors and blind spots toward which we are prone, point to resources within the Christian tradition for correcting our mistakes, and suggest some very preliminary steps toward what I hope is a way forward. Medicine as Gift
In what sense might we say that medicine is a gift? We can start with an uncontroversial claim in this setting, namely, that medicine, like all of creation, comes from God, the giver of all things. We have not created medicine, however much we have advanced the powers which it may apply. Medicine has not emerged of its own accord without reason or purpose. It is not ours by our own merit — we have not purchased it any more than we have purchased the life and health that it seeks to preserve.
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If medicine is gift, what implications follow? The most basic implication is that medicine is good, even — in the language of the Bible’s first chapter — very good. We might go so far as to ask on what other grounds medicine can be considered good, if not on the grounds of God’s own goodness. Recently, I spoke with a prominent Christian physician about a talk that he was preparing. The title of his talk posed this question: “Does faith have a place in scientific medicine?” It seems to me that putting the question that way gets us off on the wrong foot. We might better ask, “Why should we practice medicine at all? Why should we care for the sick?” Here religious believers concede too much too quickly. How sensible is it in the end to care for the sick and weak if our primary concern is the evolutionary fitness of the human population? Indeed, why should the selfish gene care for anything that diverts us from the task of generating genetic offspring? And why should we invest our time and resources in caring for the debilitated if our aim is to maximize our own temporal autonomy? The sick really are a bother after all. Is it not the case that caring for the sick only becomes fully rational, fully defensible, fully meaningful, and good, in light of the fact that just as we are given life and breath and strength as good gifts from a good giver, so we are also given the means and responsi-
Christians, we need to recover the idea that because medicine is given, it is not neutral. The third implication of medicine as gift is that, as a gift from God to us, medicine expresses truths about God and about us. About God, we learn that He cares for and is concerned about those who suffer in the body. God is the balm in Gilead, the great physician. It is Christ the Lord who heals our diseases and redeems our life from the pit. About ourselves, the gift of medicine reminds us that we are creatures who are, in the philosopher Alasdair MacIntyre’s terms, dependent rational animals.1 Contemporary medicine tends to unduly emphasize some aspects of these three intrinsic dimensions of the human experience and to ignore other aspects. Humans are, the conventional reasoning tells us, the only rational animals, and therefore human dignity (or personhood) inheres in our rational capacities. In other words, human dignity is developed with and dependent upon capacities that a mere human may or may not possess, and which each human organism must in some real sense demonstrate in order to make moral claims on the rest of us. That rather ironically puts the burden on the weak to demonstrate that they have what it takes to justify that they be cared for by the strong. If medicine, along with rationality and life itself, is a gift from God, this approach gets it exactly backward. Christianity teaches us that our dignity is given to us by the one who created us, and is given in the act of creation. For that reason, every creature has a particular dignity, according to its place in the order of creation, and among the animals the dignity of man is highest as man alone is created in God’s image. Moreover, our dignity inheres in our bodies, not in some disembodied rational capacity. Every human who is bodily present to
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bility to respond to those whose life and breath and strength are threatened or are ebbing away? We find, in other words, that the first implication of medicine as gift is that the goodness of medicine is vouchsafed by the goodness of the God who is its giver. The second implication of medicine as gift is that medicine has a given order; medicine is not neutral. We are all familiar with the phrase, “Well, that’s a given.” We might say it in response to something like, “The Cubs are going to miss the playoffs.” It means, “That is of the nature of the thing, it is intrinsic to it.” Likewise, medicine has a meaning and order that is given in the nature of the thing, one that we do not invent but rather can only to varying extents apprehend, and to which we choose either to submit, to our good, or to ignore, to our peril. Whether medicine has an intrinsic ethos, or only one imposed by people from outside, has been the subject of at least forty years of debate in the bioethics community. As Christians, we ought to be clear on which side of the debate we stand, because we know that God’s good gifts are all ordered to proper ends and uses. Just as marriage and the church, the family, food, and sex have a given order, so also medicine. Yet many Christians in healthcare seem to conceive of medicine as a relatively neutral, albeit felicitous and powerful, means to the end of spiritual conversation with patients. Medicine is seen as a wedge that opens up the heart, inviting dialogue about spiritual matters. The “witnessing” or “ministering” that ensues is thought of as the expression of Christian faithfulness, and medicine becomes one particular tool in our context for that task. Two problems emerge when Christians treat medicine in this way. The first is that we tend to take for granted that contemporary practices of medicine are good so long as they are not intrinsically evil. After all, the point is not the medicine itself, but the spiritual dialogue to which medicine opens the door. We accept the cake of standard medicine and put a flourish on the frosting, without doing the work to consider whether the cake may be ruined at the core. The second problem is that when we understand medicine as neutral, our efforts to contend for good uses of medicine seem arbitrary. In other words, if medicine is neutral, why should anyone else pay attention to your particular ideas about how it should be practiced? Why should you, in the common idiom, “impose your personal values?” Merriam Webster defines imposition as “an excessive or uncalled-for requirement or burden,” and if values are not central to medicine itself, then such impositions are rightly resisted and understandably resented in a democratic, plural democracy. As
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us, no matter how diminished in capacities, retains the dignity of being part of the human family with God as its head. In fact, just to the extent that our neighbor is vulnerable and diminished in his own capacities, that neighbor justly demands, in God’s name, that we care for him. What else could Jesus have meant in His statement that what we have done to the least of these, we have done unto Him? After all, God cares for us in our utter weakness because we cannot care for ourselves. Here we see the paschal mystery that is foolishness to the world’s wise: In the incarnation Jesus glorifies our created bodies with all of their limitations and dependencies; He dignifies all our suffering by His own bodily suffering; and He triumphs over death by dying. He exposes the lie that our capacities are our salvation. We learn that our worth, however weakened, debilitated, sick, and dying we are, is measured in the currency of His love expressed in His bodily suffering unto death.2 We humans are rational to greater and lesser extent, but we are in every way, at all times, dependent upon God and upon one another. One of the errors of modernity, MacIntyre explains, is to always set up the independent agent as the human norm — to see departures from independence as aberrations which are to be expeditiously corrected. Eric Cassell, a prominent bioethicist of the past generation, gives voice to this mindset in his conclusion that the purpose of medicine is to restore our autonomy,3 to restore, that is, our independence. But when we understand medicine as a gift from God to intrinsically dependent creatures, we see that it is a fool’s errand for medicine to set out to restore that which never really existed. We are never independent from God or one another. Like the angels and all that is not God, we are dependent upon Him who sustains all things by His powerful word. Unlike the angels, we are animals, and so, as all animals, are also limited by the contingencies of being embodied. Here we find another misunderstanding common among Christians who say, in so many terms, that our bodies are just our “earth suits.” This is an error that is cloaked in such wonderful truths that we have allowed it to become something of an axiom. The problem is that such notions suggest that we have bodies only on earth and that like a suit, the body is something which the real us can own for a time and then take off. No wonder we find others claiming, “No one has a right to tell me what to do with my body!” In contrast to these ideas, traditional Christianity holds that humans are embodied creatures, both now and forever. Our existence, now and forever, is bodily existence. We are not spirits who inhabit a body. Christ Himself is not God who inhabited a body, but is instead God-man, God in the flesh.
T o d a y ’s C h r i s t i a n D o c t o r
What difference does this Christian dogma make for the practice of medicine? It means that humans are present to us so long as their living bodies are present to us. It means that we should be very careful about saying things like, “Dad is not there anymore” when Dad is in the late stages of Alzheimer’s disease. We should not say of the child with massive injury to the brain, “The real him is gone.” By thinking theologically, we remember that both are still present to us, albeit with drastically reduced capacities and unmitigated dependence. We see, as Jesus taught and Mother Teresa reminded us, that not only are they present to us but Jesus Himself is bodily present to us in them. Can that truth do anything but motivate and enliven our care for the sick and debilitated? Knowing that medicine is a good gift and has a given order begs the question, what then is medicine for? What is its given purpose (its end)? Let me begin to answer that question by pointing to what many scholars have argued we can know by reason alone, and then complement that by what we as Christians can know by faith. By reason, according to Leon Kass (recent chair of the President’s Council on Bioethics) among others, we can discern that the proper end of medicine is health, which Kass carefully defines as an excellence of the body which is “the well-working of the organism as a whole.”4 Why the language of organism and body? Isn’t that reductionistic? Isn’t that dualistic? Doesn’t that neglect the mind and spirit? No. The focus on the body and the organism is to emphasize that medicine is a practice with limited scope and aims. In a moment we will consider in greater detail some of the problems that emerge when we ignore those limits. Why the term
Medicine as Power From medicine as gift, we turn to medicine as power and begin with a Scripture oft cited in other settings. In Paul’s letter to the Ephesians, he writes (6:12), “For we do not wrestle against flesh and blood, but against the rulers, against the authorities, against the cosmic powers over this present darkness, against the spiritual forces of evil in the heavenly places.” In a book titled, Reclaiming the Body: Christians and the Faithful Use of Modern Medicine6, — a book that I cannot recommend strongly enough — Joel Shuman and Brian Volck argue that perhaps the most important task for Christians today, with respect to medicine, is to recognize and name modern medicine as among the powers and principalities. The following paragraphs attempt to summarize Shuman and Volck’s thesis with respect to medicine as power. It will not come as any surprise to learn that modern medicine is powerful. Both patients and clinicians experience medicine to be, in Shuman and Volck’s words “a mysteriously animated social force.” “We
find,” they continue, “that medicine creates its own world. Those wishing to benefit from medicine’s power are expected to live in medicine’s world and obey its rules. . . . It is a world with its own language and logic, its own ritual practices, and its own social expectations, and those not initiated into its mysteries cannot hope to understand it.” By naming medicine as among the powers and principalities, we are not saying that physicians have ill motives, nor that medicine is evil (indeed, I have already claimed that medicine is good). Rather, we recognize the particular force that modern medicine exerts as one among the structures and authorities that order our lives, for both better and worse. To know when the influence is for better and when for worse, we have to do what we rarely do with respect to medicine, which is to think with reference to the theological truths of Christianity. And the theological point Shuman and Volck drive home is that medicine, like all of God’s good creation, is fallen and in need of redemption. The powers are good, the powers are fallen, the powers will be redeemed. First, we know that the powers in their created order are good. Indeed, we cannot live without them. Imagine life without public services, without government, without culture, without printing presses, without transportation systems, without medicine. Our flourishing would not be possible without these powers. The Apostle Paul in Col. 1:16 tells us, “In [Christ] all things in heaven and on earth were created, things visible and invisible, whether thrones or dominions or rulers or powers — all things have been created through Him and for Him.” The powers, in their created order, are good. Yet medicine, like all the rest of creation, is fallen. Shuman and Volck again:
How Shall We Then Practice?
well-working (and elsewhere, flourishing) rather than something more manageable like “the patient’s medical good”? Kass’s point is to emphasize that the pursuit of health is for something. Medicine is there to restore what can be restored of health so that the person can continue to seek the fullness of life. Toward that end, a healthy body is a great asset, but the goal is to live a good life. What a good life entails can only be known fully by the light of faith, wherein we find that the fullness of life is the life of God offered us in Christ. Margaret Mohrmann, a Christian physician and ethicist at the University of Virginia, puts it this way, “Health can never be anything other than a secondary good. God is our absolute good; health is an instrumental subordinate good, important only insofar as it enables us to be the joyful, whole persons God has created us to be and to perform the service to our neighbors that God calls us to perform. Any pursuit of health that subverts either of these obligations of joy and loving service is the pursuit of a false god. Health is to be sought in and for God, not instead of God.”5 What then is our task as Christians, in light of what we learn about medicine as a gift? It is first to see all of life, medicine included, as gift. It is second to discern, in the community of the faithful, drawing on the means God has provided, what medicine is by its given nature and its given purposes. Our goal is to understand what God would desire for us to do as stewards of His gift of medicine in our particular context.
Medicine primarily functions among the powers, we contend, by occupying a revered social position through which it appears to wield nearly sovereign control over life and death. . . . There is no apparent limit to medicine’s ambition to control the circumstances of human life and death by bringing them under human control . . . and few people seem interested in asking whether or to what extent such an aim is appropriate for creatures of a providential God. The powers, in their fallen states, make pretentious claims and seductive promises. They offer us what we want, and so we esteem them and yield to them authority that they should not have. After all, as Shuman and Volck remind us, “A denial of our own mortalities and a desire to be in control is very near the
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center of our own disordered desires.” And how does medicine appeal to those disordered desires? It offers to free us from the limitations of the body. There is more to say here than space allows, but it is perhaps enough to point to a general pattern with respect to medicine that has emerged with modernity. That is what Gerald McKenny calls “the Baconian Project,”7 after its principal proponent, Francis Bacon. The story is this: Within the Christian tradition, the task we are all to be about is to seek the fullness of salvation, what the Orthodox Christians call “theosis,” connoting participation in the life of God. Within the Christian tradition, therefore, medicine is good to the extent that it frees and enables us in our life of faithfulness, and harmful to the extent it distracts from or otherwise interferes with faithful life. According to McKenny, Francis Bacon and René Descartes began with the commitment to subject nature toward the service of one’s neighbor, to make use of it for good. They saw in the natural sciences the engine that might, if rightly harnessed, deliver mankind from its limitations — particularly sickness, weakness, dependency, and death. Bacon and Descartes’ generic Protestant commitment to helping one’s neighbor was transformed, via Bentham, Mill, and other enlightenment figures, into a more critical stance toward received tradition altogether. In the place of tradition, these thinkers advanced the ideal of commitment to the ostensibly universal morality — those obligations (and only those obligations) which can be known by reason and empirical science. Predictably, the result is a move away from particular and traditional received notions of the givenness of our stations and our obligations, and toward what Charles Taylor, in his book Sources of the Self,8 describes as the moral project of our day, which is to decrease pain and increase
pleasure. Taylor writes, “This emphasis on the relief of suffering in turn resulted in a new standard for all remaining conceptions of religious, moral, and legal order: Do they lessen the amount of suffering in the world or contribute to it?” And McKenny adds, “From now on all conceptions of order would have to present their credentials for relieving suffering to gain admission to the moral realm, credentials few such conceptions could produce.” Of course, without particular moral traditions (i.e. religions) to look to, it is very difficult and perhaps impossible to establish what counts as suffering that should be relieved and what counts as pleasure worth pursuing. The default, not surprisingly, is that suffering and pleasure are what the one experiencing them says they are. Medicine comes to serve the goal of maximal individual control over the contingencies of bodily existence, and toward that end plies the ample technical powers developed by the scientific enterprise. This leads not only to what were traditionally understood to be moral evils, things like abortion and physicianassisted suicide, but also to profound expansions of the range of medicine’s aspirations. One of the great ironies is that religion, banished from medicine as an undue traditional constraint, comes back to life as a technology that can be employed in our quest to maximize our health. Shuman and Volck put it this way, “Most of the current literature dealing with faith and medicine seems to suggest that spirituality (or religion) should be brought into the world of the clinic and retooled, when and as necessary, to fit and serve the purposes of that world. Christians, in the meantime, have mostly been content to have their tradition so named and enlisted, grateful for the validation, or at least the attention. Yet we believe this gets matters backward. It is Christianity that ought to be naming medicine, harnessing its power in the service of being a community faithfully witnessing to the work of God in the world. For only as Christians learn properly to name the world and the things in the world, can we make proper use of those things. And only as we make proper use of the world can we hope truly to flourish.” How then do we respond if we recognize medicine as among the powers which have been corrupted? Our response, Shuman and Volck tell us, is to name the powers for what they are and therefore take back authority that we have unwittingly and foolishly conceded to them. They continue: By assuming medicine and Christianity are pursuing the same things — which, coincidentally, happen to be things we want, such as health, the power to choose, and an able-
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bodied, painless death — Christians transfer even more authority from their religious community to medicine, reinforcing one of the least appreciated phenomena in Christianity since the Reformation — the growing amnesia that Christians can and should think, speak, and act differently than the rest of the world. By naming medicine among the principalities and powers, we continually remind ourselves that medicine, like all creation, must be subjugated to the pursuit of friendship with God. Ultimately, medicine and all the rest of the powers, will be redeemed. Until then, our task is to make use of the powers in pursuit of God while resisting their seductions and exposing and naming their lies. What we are after is worship rather than idolatry. Idolatry is the practice of treating any particular thing as that which that thing can never be.9 We make medicine an idol when we treat it as the means of deliverance from the contingencies of the body — something it can never be. Worship, on the other hand, teaches us what Saint Augustine called “ordered love.” We are, Augustine said, to love all elements of creation just in proportion to those elements’ true worth, a worth which is always derivative of and given by God Himself.10 We are to love everything in Him, the giver of all good things. Christian worship, therefore, is always subversive of the wisdom and powers of this age, and so to worship as we practice, we will stick out. Shuman and Volck cite Flannery O’Conner as saying, “You shall know the truth, and the truth shall make you odd.” But, as they conclude, “If the Christ we claim as savior calls us to be all thumbs, who are we to argue?” So far I have noted that medicine is a gift from God, and that along with all creation, it is both very good and yet fallen. How then can we participate in God’s work of redeeming the fallen creation, or restoring medicine to its rightful place in the created order? To point in that direction, we move to the third and final
The term vocation, and its contemporary translation, calling, have been put to widespread use to refer to any sort of work done with more than instrumental goals. For the purposes of this essay, I will focus on the concept of vocation that emerged in the Christian tradition. What may come to mind is the contemporary use of the term by the Catholic and Orthodox churches, in which a vocation is a divine calling to a particular and consecrated way of life which is ordered to serve God and the Church through specific, concrete commitments and practices. We think, for example, of vocations to marriage, religious life, priesthood, celibacy, and the like. For Martin Luther,11 the concept of vocation was central to the life of every Christian. Each of us, Luther taught, is called and set apart to participate in God’s work through particular stations in life. Luther distinguished stations from vocations, with the latter being the Christian way of living the former. The stations themselves do not effect transformation of the human heart; they do not bring about regeneration in ourselves or others. Even so, Luther notes, “persons who have not taken the gospel to their hearts serve God’s mission, though they be unaware thereof, by the very fact that they perform the outer functions of their respective stations.” Fulfilling our stations in medicine as vocations, therefore, is a way of participating in God’s work of sustaining and preserving creation. Several important implications follow from seeing the practice of medicine as a Christian vocation. First, medicine as vocation is cooperation and participation in God’s work of caring for others. God is the author of the work, but He works through us to accomplish His purposes. Luther puts it imaginatively, saying:
How Shall We Then Practice?
metaphor, medicine as vocation. Medicine as Vocation
God himself will milk the cows through him whose vocation that is. He who engages in the lowliness of his work performs God’s work, be he lad or king. To give one’s office proper care is not selfishness. Devotion to office is devotion to love, because it is by God’s own ordering that the work of the office is always dedicated to the well-being of one’s neighbor. Care for one’s office is, in its very frame of reference on earth, participation in God’s own care for human beings. Second, medicine as vocation specifies for us our relationship within the community of the faithful. With respect to vocation, what one does is dependent on who one is, and who one is is not something one can decide for oneself. We can receive a vocation and live into its
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How Shall We Then Practice? 18
requirements, but we cannot make those requirements up. The vocation itself confers on us particular privileges, authority, and obligations. It tells us what our work is in the task of contributing to the good of the community. Two points here bear more emphasis. The first is that the particular station or vocation is not incidental but rather a work given by God and ordained to its own given ends for the good of the community to which it is accountable. An example may help to drive this point home: Being a husband is a vocation. It is not open for us to invent what it means to be a husband, notwithstanding the regrettable contemporary phenomenon of Christians making up their own marriage vows. We husbands are accountable to the community of the faithful regarding how we fulfill our vocation. Being a husband is not a neutral thing that we make good by praying with our wives, however good it may be to pray with our wives. Likewise, being a physician is not a neutral thing made good by sharing the gospel with our patients. Both vocations are good in themselves and have their own given order and responsibilities which we can apprehend or ignore, but which are not subject to our own creative revisions. C.S. Lewis described this as the difference between the traditional mindset of initiation into an identity and practice, and the modern mindset of indoctrination. In this respect, what is true of being a husband is also true of medicine. That vocation is for and in the life of the body, the community of the faithful, leads Shuman and Volck to say that, properly speaking, as Christians “we never really go to the doctor alone.” The church weighs in on and helps us to discern the nature of the gift we have been given in medicine, and how that gift is to be used in a particular setting. In other words, it is not our right to practice medicine according to our own preferences, without the sanction and if needed censure of the rest of Christ’s body. Rather, as Shuman and Volck put it, “Especially when we are sick, we approach medicine as part of a suffering people hoping to remain faithful to our Creator, reserving to the gathered community of which we have been made members the right to judge the aims and means of medical practice in the light of the crucified and risen Jesus we worship.” In medicine, practiced as a vocation, therefore, by participating in the work of God, within the body of the faithful, thinking theologically, and striving to discern the given nature of medicine and its good uses in our day, we participate in God’s work of redeeming that power and principality which has fallen. We stand as living reminders that the secular vision is not given. It is not to be taken for granted. And we look forward with hope to the day when all will be made right, sickness will be no more, and medicine, like the grave, will
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be swallowed up in Christ’s victory over sin and death. Conclusion In conclusion, through the metaphors of gift, power, and vocation, so richly elaborated in the Scriptures and the Christian tradition, we begin to see how the practice of medicine can and should reflect and embody the Christian story. Creation is good, creation is fallen, creation must be redeemed. Medicine is a good gift. With all creation, medicine is fallen and becomes one of the powers and principalities which order our lives in idolatrous ways. Along with all creation, medicine will ultimately be redeemed in the age to come. In the in-between time, it is our task to happily participate in God’s work by responding to the calling to serve in the vocation of medicine, to make the flourishing of the body our concern so that our patients can return to the task that is given to all, the task of knowing, loving, and serving the Lord. ✝ _____________________________ Bibliography See Alasdair MacIntyre, Dependent Rational Animals: Why Human Beings Need the Virtues (Open Court: 2001). 2 For a powerful explication of human dignity and our obligations to one another in our weakness, see Pope John Paul II’s encyclical The Gospel of Life. 3 E.J. Cassell, “Consent or obedience? Power and authority in medicine” (N Engl J Med) 2005; 352 (4): 328-30. 4 L.R. Kass, “Regarding the end of medicine and the pursuit of health” (Public Interest) 1975 (40):11-42. 5 Margaret Mohrmann, Medicine as Ministry (Pilgrim Press, 1995): 15-16. 6 Brian Volck, Joel James Shuman, Reclaiming the Body: Christians and the Faithful Use of Modern Medicine (Brazos Press, 2006). 7 G.P. McKenny, To relieve the human condition: bioethics, technology, and the body (Albany, NY: State University of New York Press; 1997). 1
Charles Taylor, Sources of the Self (Cambridge University Press, 1989). I owe this formulation, as best I can remember it, to a lecture delivered by Paul Griffiths, a Catholic moral philosopher now at Duke University. 10 C.S. Lewis says much the same thing in his book The Abolition of Man. 11 These references to Luther’s thought are owed to: Gustaf Wingren, Luther on Vocation (Wipf & Stock Publishers, 2004). 8 9
Farr A. Curlin, MD, is a hospice and palliative care physician, researcher, and medical ethicist at the University of Chicago. Dr. Curlin’s empirical research charts the influence of physicians’ religious traditions and commitments (and their secular analogues) on physicians’ clinical practices. As a medical ethicist, he is interested in questions about whether and in what ways physicians’ religious commitments ought to shape their clinical practices in our plural democracy. As founding Co-Director of the Program on Medicine and Religion (pmr.uchicago.edu), Dr. Curlin is working with Daniel Sulmasy, MD, PhD, and colleagues from the University of Chicago School of Medicine and Divinity School to foster inquiry into and public discourse regarding the intersections of medicine, ethics, and the religious traditions.
C O M M U N I C AT I O N :
The physician should consider the contextual factors of any conversation. • What is the nature of the relationship? Communication differs if the relationship is recent or long-term, one in which there is shared history between participants.
by Allan M. Josephson, MD
Context
The Need to be Understood
M
y daughter, currently a dermatology resident, recently evaluated a patient who required the application of an ointment to his back. The patient was instructed to have someone help apply the ointment to difficult to reach areas, to which he poignantly responded, “I don’t have anyone to help me with this.” More and more social needs spill into our offices, as medical work becomes complicated by the serious psycho-social problems of our patients. Such individuals seem to need so much more than basic medical care. Increasing numbers of conditions are influenced by our culture and how individuals conduct their lives, often living with no margins of time and energy.1 Make no mistake; communication with our patients about all aspects of their lives is increasingly an important part of our profession. Our patients’ medical needs are always accompanied by the simple human need to be understood by another person. Paul Tournier wrote, “No self knowledge is gained by introspection or of the solitude of one’s own diary, only by opening up to a confidant freely chosen does one grow.” 2 It is incumbent on Christian physicians to be “counselors” and “teachers,” with communication the defining element of those informal titles. Indeed, counselor and teacher are two terms applied to Jesus in his ministry (Isaiah 9:6; Matthew 7:28-29). Not surprisingly, the need for effective communication also exists in the physician’s personal life. Effective spousal and parental communication is a cornerstone of healthy family life (Josephson, 2007).3 For physicians in the clinic and at home, communication is a skill to be nurtured. This brief review will assist the physician in connecting at a deeper level with patients and those in his or her personal life, ending with a biblical model on how to handle difficult conversations, using Jesus’ example.
The development of good communication skills is crucial to optimal doctorpatient interaction
Communication: The Need to be Understood
• What is the setting of the conversation? Experienced physicians know that a cancer diagnosis initially conveyed often leads to little communication being remembered by patients or family members after the unsettling announcement. • Who is the sender of the communication? The sender needs to know himself, his agenda, and his typical ways of communicating. • Who is receiving the communication? It is important to tailor a message to the person receiving it, to understand where that person “is coming from.” Conveying clinical information to a patient who is a healthcare professional is a different task than communicating with one who is medically naive. Similarly, it is a very different parental experience communicating with an adolescent compared to talking to a school-aged child. • What is the gender of the participants? Male and female differences powerfully shape personal communication. Listening Not long ago, I evaluated a patient suffering from depression. She asked, “Are you the kind of psychiatrist who talks to people?” This amazing question never would have been asked a decade or two ago. If the psychiatrist, who should have time to explore problems, has no time to do so, what of the plight of the busy primary care practitioner? Rest assured, without time, there is no meaningful communication. It is axiomatic that no conversation gets off the ground without participants listening to each other. What should the physician listener consider? • Do not interrupt. • If one’s emotions are becoming intense, resist a quick emotional response which can crush further conversation. • Listen for themes — what the person is saying “between the lines.” • Place yourself in your patients’ shoes; empathize with them. • Evaluate the merits of a message, without judging the person. • Ask sensitive questions; these can often clarify things.
versations, getting to know someone, can prepare for a deeper relationship. But for some, brief interactions may end there, such as conversations at a spouse’s yearly business party. The importance of routine social communication is underscored in that patients often know whether they like a physician much sooner than they know whether he or she is medically competent. In order to understand another person, it is essential to recognize the difference between the “content” of communication and the “process” of communication. Content refers to the facts communicated and process refers to the overarching theme giving meaning to the facts. Content is the message of the sender, such as the physician informing the patient of a treatment plan or a parent describing an itinerary for a family vacation. The process involves emotional connection, hearing beyond the facts and getting the big picture. It is healing for any patient to have their physician understand what he or she is going through and to have the doctor communicate that understanding back to the patient. When communication is vexing, identifying its process elements can open up new areas of understanding. A wife complaining of her husband’s frequent Saturday morning golf outings may really be saying: “I’d like to be with you; our children need you,” rather than making any specific negative comment regarding him or his behavior. A father who reprimands his son for not completing an assigned task may believe him to be irresponsible. The process in this instance may revolve around the son being fearful of making a mistake, which would be harshly criticized by his emotionally distant father. The highest level of listening, a springboard to effective communication, is to pay attention to the “process.”
The Interaction Social conversation often initiates a relationship. Humor is a valuable asset in communicating as it puts people at ease and gives them something, preparing them to feel that the conversation is worth continuing. Social con-
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Within this framework, Jesus was the ultimate process communicator. He walked with people, talked with people, ate meals with people, and in doing so communicated on matters of deep interest. The superb volume of the
Communication: The Need to be Understood
noted British preacher, teacher, and writer, G. Campbell Morgan, The Great Physician – The Method of Jesus with Individuals, reviews Jesus’ teaching and conversations with over forty different persons, modeling how to understand the process of others’ communication.
“No one Lord”, and Jesus said simply, “Neither do I condemn you. Go your way, from now on sin no more.” Why is this such an effective model for communication? To a woman facing condemnation and death, Jesus loved her, supported her and empathized with her. Yet, he gave her so much more. In many therapeutic situations in clinical psychiatry, the patient needs understanding and assurance in order to feel comfortable in sharing his or her story. However, if all the patient receives is support, it may not lead to the necessary behavioral change. When the patient feels accepted, he or she needs to be brought to the point of change, which Jesus clearly illustrates in His explicit directive to the woman, “Go sin no more”. Effective psychotherapy challenges and confronts patients to change, and this is also true with children or spouses who are challenged to change. Either extreme does not work. Confrontation without love — who would want to listen to this? Support without expectation of change — is this therapy at all? In difficult conversations, effective communication is always grounded in the love and empathy of the communication’s sender. Yet this deep understanding is also linked with an expectation of change, or action, on the part of the communication’s receiver. It is often the physician’s role, as a professional or as a parent, to lovingly convey an expectation. Many of Jesus’ interactions in the New Testament involved discussions in which something was asked of the participant. After making others feel accepted and secure, He got down to business. When individuals left a conversation with Jesus, they felt understood. May this be the mark of the Christian physician. ✝
The Difficult Conversation Bibliography
The social scientists of the Harvard Negotiation Project have summarized fifteen years of research on how to manage “difficult conversations” with understanding and, ultimately, success (Stone et al, 2000). Social conversation, chatting, or sharing joys are relatively easy; it is easy to steer a ship when the seas are calm. But how does one proceed in a difficult conversation? Again, Jesus provides a guide. In John 8, we find a remarkable incident which serves as a model for all difficult conversations. In the story, the Pharisees brought a woman caught in adultery and challenged Jesus, again using the word “teacher.” “This woman has been caught in the very act of adultery. Now in the law Moses commanded us to stone such a woman, what then do you say?” Jesus stooped down and wrote in the ground and asked, “He who is without sin among you, let him be the first to throw a stone at her.” When they heard this, they all left. Jesus was then alone with the woman, and asked her, “Where are the others? Did no one condemn you?” The woman said,
Morgan, G. Campbell. The great physician: The method of Jesus with individuals (Grand Rapids, Mich.: Fleming H. Revell, 1982). Stone D, Patton B and Heen S. Difficult conversations: How to discuss what matters most (New York: Penguin Books, 2000). ________________________________________ See Swenson, RA. Margin: Restoring emotional, physical, financial, and time reserves to overloaded lives (Colorado Springs: NavPress, 2004). Tournier, P. To understand each other (Richmond, Va.: John Knox Press, 1973), 23. 3 Josephson, A. (Primary Author; Work Group on Quality Issues): “Practice Parameter for the Assessment of the Family.” American Academy of Child and Adolescent Psychiatry Official Action. J Am Acad Child Adolesc Psychiatry 46 (2007): 922-937. 1
2
Allan M. Josephson, MD, is Professor of Psychiatry and Chief of Child and Adolescent Psychiatry at the University of Louisville, where he is the CEO of the Bingham Clinic. He is published in the areas of family therapy, psychiatry and spirituality, and psychiatric education. He is a national leader in child and adolescent psychiatry. Dr. Josephson is recent past president of the Psychiatry Section of CMDA.
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The Providence of the COMFORT: Letters from Haiti
by Clydette Powell, MD, MPH, FAAP
Letters from Haiti while o Hospital Sh ip USNS CO n the MFORT January 15 – February 15, 2010
“‘For the mountains may be removed and the hills may shake, but My lovingkindness will not be removed from you, and My covenant of peace will not be shaken,’ says the LORD who has compassion on you” (Isaiah 54:10).
A
t the first break of news about the earthquake in Haiti on January 12, I knew I was called to serve those who had been injured. It was just a matter of finding the best way to get there. Through a remarkable series of rapid events, I was offered a place on board the USNS COMFORT, the US Navy’s white hospital ship emblazoned with red crosses, where I would work nearly non-stop for the next four weeks. What follows are excerpts of letters to my mother over that time.
admiration. He is a wise leader, humble, confident, and deeply caring about the team. His relationship skills are exceptional; his professional military experience is deep. The team morale is high; everyone is “pumped” for tomorrow’s morning arrival in Haiti and the humanitarian mission over the next several months. The Navy discipline and esprit de corps are outstanding.
January 19
Our USNS COMFORT dropped anchor in Port-au-Prince before daybreak, just before a “welcome” quake of 6.1! The first helicopters were off at dawn to retrieve patients from the USS CARL VINSON. What a sight to see them careening over the harbor, with Haiti’s mountains in the background, off to the humanitarian mission we so eagerly have awaited in these four days since sailing out of Baltimore! On board, the Casualty Receiving area (ER) was busy with its first patients. I quickly found a young Haitian woman, thirty-two weeks pregnant, who had suffered multiple episodes of blunt trauma to her abdomen and
It has taken us almost four days to sail from Baltimore to Haiti, traveling at fifteen miles per hour! I cannot fully describe how privileged I feel to be a part of this humanitarian mission to Haiti, in the wake of the earthquake’s devastation barely one week ago. As an American citizen, I am honored to represent my country and USAID (the US Agency for International Development) in this endeavor. Thank you so much for your prayers and your support! The USNS COMFORT team on board is impressive. CAPT James J. Ware, the Commanding Officer, has my full
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January 20
January 22 Among all the suffering and cries we have heard over these past days, the best sounds were the new cries of a little four-pound, five-ounce preemie named Esther who arrived by C-section. She was born in our operating rooms on the ship some seven weeks before she was due. They say this is a mile-
stone because little Esther is the first baby born on board since the ship was converted from an oil tanker to a hospital ship back in 1987! January 30 In God’s foresight and His plans for me years ago, my training in child neurology has been custom-made for this mission. The US Navy did not deploy a single pediatric neurologist for this mission! So I, the civilian doctor, am it! With all the head trauma and spinal cord injuries, crush injuries, and seizure disorders secondary
to brain injuries, we have been busy. I am working some very long hours, but I am in my passion. Of all the ways for me to help the Haitians in this crisis, this is the best. And I am getting a lot of exercise up and down the ladder wells (stairs) all over this ship. Mom, the COMFORT is three football fields in length and the equivalent of ten stories high! I am so glad I packed my running shoes! January 31 This evening at the ship’s chapel we attended a funeral/ memorial service for a ten-year old patient, Alexis R, who died four days after contracting meningitis. Her mom grieved deeply, clutching her stomach and saying she still remembered the labor pains she had for her daughter when she was born. Between tears, she cried out details about her daughter — little conversations they had as mom and daughter, ways that Alexis helped her at home, and how this child was the most treasured among her other children. The American chaplain and a Haitian pastor co-led the simple
The Providence of the COMFORT
burns during the quake. Her unborn child was moving in her womb — visibly. I was glad to see those movements and relieved to learn that she had had no premature vaginal bleeding. Then the Cas Rec doctor asked if any one spoke French so the patient could understand his process to dress her severe burn wounds. I immediately volunteered and translated for him. Also at her ER bedside, the ship’s chaplain asked me to translate his prayers for her, as we both tenderly held her arms. What a joy to be able to help! She seemed appreciative and relieved. My very first contact with the wounded of Haiti! What a privilege. Thank you, Lord.
service of hymns, Bible readings in English and French, and prayers. What moved me the most, however, was seeing about four rows up in the front of the chapel the mom of Catherine Jean B, a baby who had just died earlier this morning. This mom had given birth to Catherine one day before the earthquake. The next day, the quake killed her husband, destroyed her home, and forced her onto the streets, twenty-four hours post-partum. Although Catherine had survived briefly, now she was gone. Seeing that mom sitting in Alexis’ funeral service, this mom newly widowed, newly bereft of her baby, newly homeless, just tore at my heart. Although the
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service was for another child, my greater grief was for a mom who had barely had time to hold her own little baby in her arms. As the service came to an end, each person lined up to come by Alexis’ mom and hug her, then they slowly filed out of the chapel. The Haitians were singing over and over again a song in Creole; it included the words “Hallelujah.” As we left the chapel, and as we silently went up the many steps in the ladder-well back to the patient wards, I heard the clicking of crutches against each of the metal steps in the ship. I had forgotten that to arrive at that chapel, some patients on crutches had made the big effort to climb up and down those stairs . . . to honor this mom and perhaps to give thanks that their lives were spared. In that passageway, Catherine Jean B’s mom broke down and sobbed. . . . I could not hold back the tears, myself.
Republic. Because the story of this child and her dad and the timing of events were extraordinary, I must share with you God’s providence in her life and mine. I had first met Faika and her father in our PICU on January 24. Not home when the earthquake struck, her dad was spared. But when he arrived home, he found that his wife and two of his daughters had immediately died. His third daughter Faika somehow survived, with head, leg, and pelvic injuries, and was rushed to a field hospital in Port-au-Prince. Over the course of time, Faika developed multiple medical problems, including kidney failure and fluid in her lungs, which caused her to stop breathing and be placed on a breathing machine. Two weeks later, she was transported by helo to our PICU here on the USNS COMFORT, where she remained on a breathing machine for another few days.
February 7
Faika nearly died. Yet, over the course of her PICU stay, she began to improve slowly; her kidney failure and respiratory distress resolved. She received a transfusion for marked anemia, and finally was well enough and awake enough to recognize her very grateful father. Throughout all this uncertain course, her father quietly expressed his faith in God and his unending hope for his daughter, the only precious thing that remained to him. He had a deep faith in the Lord in the face of unimaginable tragedy. Over the next two weeks, I followed Faika’s course, both in the PICU, where I was spending most of my
Oh, Mom, your notes sustain me. They make it possible for me to do this hard work and to reap rewards in so many ways. But I kept thinking about this day one year ago when Dad died. No one here on the COMFORT, no one in Haiti, knew this day’s personal significance. Yet, God has placed this work before me, and so it helps me to focus on His tasks for my day. Today in a helicopter (helo) I accompanied a ten-yearold girl named Faika from the USNS COMFORT to a field hospital, near the Haitian border with the Dominican
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As I was making my informal site visit, taking some photos, and waiting for a return helo, I heard someone call out my name “Clydette??!!” I turned around, astonished that anyone could know I was here. It was my dear friend Diane, also a pediatrician and whom I had last seen in February 2009 in Asia. Diane was a missionary doctor in Pakistan. Temporarily based Stateside, she had volunteered to come to Haiti and help in the relief effort. She was the only pediatrician at FDP and had extensive experience in refugee health care. I had no idea she was in Haiti, let alone at FDP. You can imagine my surprise in seeing her. Moreover, I was delighted that I could hand over Faika’s care to FDP’s only pediatrician and a trusted friend. That in itself seemed divinely orchestrated. However, what made this meeting up with Diane even more significant and personal was that exactly one year ago to the date — February 7, 2009 — my father had died, and Diane had been with me after I received that news. She had been an immense source of comfort. All today, in the back of my head, and deep in my heart, I wondered what God would do to address my grief. Here was Diane, the only person in Haiti who knew and had experienced my own personal earthquake 365 days ago. Diane and I hugged hard and long. I brought her over to Faika’s bed and introduced her to my patient and her father. Forty minutes later, the noise of thumping blades suddenly announced the return to FDP of my helo ride. I quickly ran for last hugs with Faika and her dad, and then Diane one more time, and then I ran for the landing zone. As I jumped on board the helo to fly back to the USNS COMFORT, I wished Dad could have seen all that had happened. Then I realized, “Of course he is, and he is looking at all this from the best seat in the House.” ✝
The Providence of the COMFORT
time — and then on the patient wards after she had been transferred. Conversing in French, her father and I spoke of their circumstances and needs, but Faika remained silent, never saying a word, likely traumatized by all that she saw, in the earthquake and in the PICU. Today was her patient discharge day from the COMFORT. Though not completely healed, she was ready for transfer back to the mainland. This morning, I waited with them in Cas Rec (the ship’s ER) for her move up to the flight deck and helo transport out. She and her dad were excited though apprehensive about what awaited them. Their home and his livelihood had been completely destroyed by the quake, and they were being transferred to place far from Port-auPrince. I was initially very concerned about this destination, and fought that decision by the discharge planners; but this destination decision (FDP) was nonnegotiable at that point, and the father convinced me that he wanted the best for his only daughter, no matter where that place was. I decided to stay with them as long as possible. To my surprise and delight, at the last minute the “air boss” gave me the thumbs up to accompany Faika and her father in the helo transport to FDP. Oh, I was thrilled! They first loaded Faika’s litter into “the bird,” and then her dad and I got on board, while the helo’s rotor blades thumped loudly. When we suddenly and finally lifted up from the flight deck, Faika gripped my left hand; and in my right hand was her dad’s. We became a threesome, flying over the bay, over Haiti’s capital city, and then into the rural interior, arriving some 15-20 minutes later at FDP, which none of us knew. As soon as the helo pilots dropped off Faika, her dad, and me, they told me they had another run to make but promised to pick me up on their way back. “Powell, you’ve got 40 minutes to get your work done at FDP, because we cannot wait for you at the landing zone, and we don’t know when we will be back.” FDP’s site looked well organized and welcoming. We were greeted by an orthopedic surgeon from Chicago and two Creole speaking female volunteers working in the triage tent. The FDP surgeon carefully took off Faika’s wound dressings and commented on how well cared for she had been on the COMFORT and how nicely the wounds were granulating in. The FDP staff treated Faika and her dad kindly and helped them start the process of admission to this field hospital. Knowing I had just 40 minutes till my own pick-up, I decided to wander around and check out FDP hospital where I was placing Faika and her dad — and potentially other patients from the COMFORT.
Clydette Powell, MD, MPH, FAAP, serves as medical officer for the US Agency for International Development (USAID) in Washington, DC. Her work focuses on TB/HIV, human trafficking, and civilian-military coordination in health. Clinically, she volunteers at Children’s National Medical Center’s pediatric HIV clinic in DC. A graduate of Johns Hopkins Medical School, she did her residencies in pediatrics and child neurology in Pittsburgh, and her MPH at UCLA. She is a Trustee of CMDA.
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E R O M
Standing Orders for the Christian Medical Student by Ronald L. Machado, MD
This is the second article on this subject by Dr. Machado. The first appeared in Volume 39, No. 2 (Summer 2008). The first three orders were: #1 – Don’t Stop, #2 – Beware, and #3 – Be Prepared to Change.
s Christians in the medical field, exhortation and encouragement are vital for preventing the ill effects of “the world” on our lives. Early Christian disciples received many challenges from Jesus Himself as well as from various New Testament writers. These same challenges are relevant to the Christian medical student. Using typical scenarios in which medical students might find themselves during their training, I hope to demonstrate the pressing need for constant spiritual challenge and encouragement from God’s Word.
“Then he opened their minds so they could understand the Scriptures. He told them, ‘This is what is written: The Christ will suffer and rise from the dead on the third day, and repentance and forgiveness of sins will be preached in His name to all nations, beginning at Jerusalem’” (Luke 25:45-47).
A
Order #4 – Suffer A standing order to suffer may not seem like much of an encouragement. Some definitions of “suffer” include: to undergo hardship, to feel pain, to have a disease, and to endure or undergo. Medical students will suffer many trials during their training. Early on, the seemingly endless rounds of exams on overwhelming amounts of material put academic and emotional discipline to the test. During the clinical clerkship years, students may find themselves up against strong personalities who use intimidation and denigration in their approaches to teaching. Then as a resident, intern call schedules, followed by the increased burden of personal responsibility for patients’ well-being are sufferings that cannot be ignored. Coping with issues such as medical errors and patient deaths in addition to personal life stressors can take its toll on emotional and spiritual health. Suffering in these ways should lead the Christian to reflection on the suffering of Jesus.
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As Christian medical students endure hardship, they can be encouraged by the sufferings endured for them by the Savior. In addition, as medical students endure these sufferings, I believe that they achieve a unique closeness to God as illustrated by the apostle Paul’s words to the church in Rome: “Now if we are children, then we are heirs — heirs of God and co-heirs with Christ, if indeed we share in his sufferings in order that we may also share in his glory” (Romans 8:17). Paul adds significant encouragement to his words in the very next verse: “I consider that our present sufferings are not worth comparing to the glory that will be revealed in us” (Romans 8:18). These truths are remarkable mysteries that Christian medical students should frequently meditate upon and tightly hold onto throughout their training and career. I know that when I put my sufferings in the context of Christ’s suffering and promised glory, it provides a deep and spiritual encouragement that increases my perseverance.
“Whoever wants to become great among you must be your servant, and whoever wants to be first must be servant of all — just as the Son of Man did not come to be served, but to serve, and to give his life as a ransom for many” (Matthew 20:26-28). The standing order to serve is another example where the benefits are not easily seen. Definitions include: to work for; to be subordinate to; to be a servant; to be of use; to supply the wants of. How can orders like this be of benefit to a professional student? In some ways, the student will have no choice but to serve, such as in the typical medical school hierarchy where the medical student stands at the end of the line of knowledge and ability in comparison to the residents and attending physicians. The medical students may get mundane tasks as part of the team, but in return they get the experiences and teaching required to move up the ladder. As an example, I remember being a third-year medical student on my internal medicine clerkship and being in awe as I witnessed the seasoned patient-care abilities of the fourth-year medical student extern on our team, while I struggled to figure out where to find some gauze, butterfly needles, and tiger top test tubes. The act of serving the team was ultimately beneficial to my own training. Another form of serving that medical students should be familiar with is what can be called “ownership” of the patient. I hear this term frequently as I discuss the patientcare abilities of our residents with other faculty. A seeming contradiction of terms, to show this “ownership” of patients is to actually demonstrate the wholehearted desire to personally serve the patients in whatever way is needed to improve their health. The patients are approached as if “owned” by the physician and, therefore, a sense of urgent personal responsibility is taken for their care. Medical students that grasp this concept will benefit from its wisdom, and so will their patients. And finally, the success and prosperity that come to a physician in the United States lead to an ultimate choice to serve best illustrated by Jesus Himself. “No one can serve two masters. Either he will hate the one and love the other, or he will be devoted to one and despise the other. You cannot serve both God and money” (Matthew 6:24). The new physician will be faced with choices when prosperity arrives. Will the presence of wealth lead to choices that keep them close to God and His kingdom, or will they be led in a direction that removes the impor-
tance of God in their life? The apostle Paul poignantly challenges the wealthy in his letter to Timothy: “Command those who are rich in this present world not to be arrogant nor to put their hope in wealth, which is so uncertain, but to put their hope in God, who richly provides us with everything for our enjoyment” (1Timothy 6:17). I am humbled when I meet others that have much less than myself, and yet I sense their tireless efforts in their occupations and service to God, all done with much less daily grumbling than my own. I am left with a recurring need to consider my stewardship of what God has provided and assessing whether or not my life is being lived in service to the correct master. Medical students need this standing order so they remember that their eternal hope is in God.
I cannot
emphasize
enough to Christian medical students that their
spiritual life
is under attack.
Standing Orders for the Christian Medical Student
Order #5 – Serve
Order #6 – Stand “Stand firm. Let nothing move you. Always give yourselves fully to the work of the Lord for you know that your labor in the Lord is not in vain” (1 Corinthians 15:58). At some point in a physician’s career, he or she will feel that a patient needs something done to get him better that someone else does not think that he needs. The physician will have to make a choice to either defer to the other physician’s opinion or hold his or her ground. For example, I was supervising a resident caring for a female patient with chronic abdominal pain, weight loss, abnormal labs, abnormal gall bladder ultrasound, and no discernible ejection from the gall bladder on a nuclear medicine scan. These abnormalities seemed to indicate the
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and against the spiritual forces of evil in the heavenly realms” (Ephesians 6:10-12).
need for acute removal of the gall bladder. However, it was not until numerous calls were made by the resident to the consulting physician that it was finally decided to remove the patient’s gall bladder prior to discharge. As a result of the resident’s standing firm regarding a medical problem with evidence to support it, the patient received the care she needed. Christians must make spiritual choices like this. I cannot emphasize enough to Christian medical students that their spiritual life is under attack. Many times these attacks are subtle, slow, and can be absolutely devastating. To go through the medical education process without clearly recognizing that you are putting your spiritual life at risk is unwise. Maintaining closeness to God and fellowship with other believers requires as much discipline, if not more, than what is required to sustain oneself through medical school and beyond. Lines must be drawn, and students must prayerfully keep from crossing those lines with regard to money, relationships, leisure, and many other life areas. Christian medical students must stand firm on the foundations of their faith, and not be swayed by worldly influences. As difficult as it may seem to balance profession and faith, it shouldn’t be. The choice to labor for God and not to fall into worldly pits should come easily for Christians who truly understand their faith. The power to stand up to the traps and pitfalls of the world is easily accessible through the promises of God in His Word. “Finally, be strong in the Lord and in His mighty power. Put on the full armor of God so that you can take your stand against the Devil’s schemes. For our struggle is not against flesh and blood, but against the rulers, against the authorities, against the powers of this dark world
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Paul encourages the Christians to stand in their faith four separate times in Ephesians 6. Just as a medical student will take notice if the same medication side effect is frequently mentioned during the course of a lecture, the Christian should take notice of this repeated exhortation to stand. So much of the focus of learning in medicine is on the “flesh and blood” of the patient, but Paul challenges the Christian to be looking beyond this. The Christian medical student should not allow the worldly pursuit of a medical career to consume his or her ability to stand spiritually. The student should be clothed with truth, salvation, righteousness, the gospel, and God’s Word. The wearing of this spiritual armor should be transforming, enabling the Christian medical student to stand firm against the fleshly attacks that will come while the student pursues a medical career. Conclusion Suffer through all the trials of your medical education. Serve God and your patients tirelessly. Stand boldly with the truths of your faith in the thick of the spiritual battle for your life. Jesus did all these things and more for you. He stands even now before God the Father on your behalf, knowing your great spiritual need. I challenge medical students to heed these orders that it may be clear to all that they are in Christ — standing. ✝ Scripture references in this article are from the NIV.
Ronald Machado, MD, is a board-certified family physician and a member of the family medicine faculty at the Tallahassee Memorial Family Medicine Residency Program in Tallahassee, Florida. He attended the Florida State University Program in Medical Sciences (PIMS) and received his MD from the University of Florida College of Medicine. He has been a member of CMDA since 1993.
Kay Kerosene by Ashley C. McGee, MD I entered medicine to be the hands and feet of Christ to my patients. After residency and a stint overseas I have been working in a primary outpatient setting for about two years. It did not take long for me to get caught up in the games of the office setting. I found myself referring to patients by little “nicknames” or saying, “They’re just crazy” or “There goes my day” when I see certain names on the schedule. I would occasionally feel convicted by this, but in a moment of stress I would find myself doing it again, obviously not having truly repenting of what I had done. Certainly, no one in my office stopped me from the behavior, and if anything they fanned the flames of my sin. There is one particular patient whom I will refer to as “Kay.” Kay is notorious for reeking of kerosene. Obviously it is the only source of heat she has in her home. She lives alone and is very noncompliant. She has some mild mental deficits. On one visit I put her in a hall by herself so I could keep the door open and not get a headache from her odor. One day she came in and was following her same routine. She would tell me nothing was wrong and she was only “Here by His grace.” She was sitting in the room covered in Vaseline and flipping through her tattered Gideon Bible. After seeing her that particular day I walked out to the nurses’ desk as I usually do to fill out paperwork before dismissing the patient. I do not recall what comments I made about her to my staff, if any, that day. However, I will never forget what happened when I walked back into the room. Out of the blue, Kay said something like this, “I know what they are saying about me. You know, they said stuff about Jesus, too. When those soldiers had Him on the cross they made fun of Him, too.” I do not know what she meant by what she was saying, but I know what I heard. The Holy Spirit used her to speak straight to my heart. What was I doing? I immediately went back to my office nearly in tears and immediately asked for forgiveness from the Lord. How dare I treat my patients the way I have been treating them! Every patient who comes in is loved by God just as much as He loves me. How can I let off-the-cuff comments come out of one side of my mouth and then expect encouraging words, sharing the love of Christ, to come out of the other? Scripture tells us that this is not possible. I told my nurse, who is also a strong believer, of my revelation. She said she understood how I felt and that she would help to hold me accountable if I would hold her accountable, as well. In the weeks since this incident my practice has changed. I have learned that every patient who walks into an exam room has a need and God has placed me there to help Ashley C. McGee, MD, lives in meet that need. I have also learned Greenwood, SC, with his wife, that I am to give time to and love each Sarah, and three children. He has patient as Christ would. Certainly, I been practicing Family Medicine fail at times, but overall it makes a in Ware Shoals, SC, for the last two much smoother day. Instead of sayyears. He has done medical mising, “What does that crazy man want sions in several different countries, today?” I have found it much more most recently through Volunteers pleasing to say, “What can I share in Medical Missions. Dr. McGee and his family about you, Lord, today?” or even posspent about six months at Tenwek Hospital with sibly, “What can this person share World Medical Mission after completing residency. about You with me?”
BIOETHICS SERIES
Informed Consent by Nick Yates, MD, MA (Bioethics) – Chair, CMDA Ethics Committee The medical principle of “informed consent” raises — depending on who is providing the discourse — a number of important issues; however, there are at least two issues: informed and consent. The Hippocratic Tradition is a foundational pillar of this principle in that emphasis is placed on truth-telling, the rights and needs of the patient are recognized, and the sanctity of life is upheld. In addition, the Christian ethic of care broadens the principle to include all who are in need of medical care, especially the widowed, the orphan, and the sojourner (James 1:27, and Luke 10). In a slightly different vein, more recent considerations of “informed consent” have abutted HIPAA (Health Insurance Portability and Accountability Act) and query the absolute privacy of the various types of personal healthcare information. These very real issues emphasize the importance of obtaining consent from the informed patient and being sure that the patient has appropriate and adequate medical information. INFORMED CONSENT: HEALTHCARE DECISION-MAKING Informed healthcare decision-making requires clear dialogue between the physician and the patient and the family. This communicative process is an integral part of the physician’s fiduciary responsibility to the patient, where the physician provides protective and competent care. In so doing, the physician puts the patient’s needs ahead of his own, as the physician intends to assist the patient in returning to the normal state of health. In offering competent medical care, the physician also is expected to give clear, comprehensive, and complete medical information that is germane to the medical condition and appropriate for the patient to make the necessary medical decisions. Often, in this type of relationship, there is joint decision-making where neither the physician nor the patient (or family) exercises authoritative autonomy, and the cooperative decision reflects mutual and considered understanding. The primary tenants of informed consent are: 1) the presentation of medical information in a manner understandable to the patient, 2) the patient necessarily must have the decisional capacity to make the medical choices, and 3)
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the patient must have the clear opportunity to make a decision that is free of coercion. The presentation of information may occur in multiple venues: spoken word, written word, or sign language. There are even examples of eye blinks and hand squeezing if the information and questions are simplistic enough. In dealing with a situation where language interpretation is needed, it is best to use an independent interpreter and to decline the use of a member of the family; if a family member is used, confidentiality may be lost, credibility may be damaged, and the situation may become coercive as the physician cannot be confident of what is really being said to the patient. In addition, the family may be coercive during discussions with the patient and the patient may feel intense pressure to please the family. Furthermore, the physician may become coercive — intentionally or not — through the explanation of the medical information. Part of the physician’s fiduciary responsibility is to provide a safe and comfortable atmosphere for the patient to reach an informed decision. Decisional capacity is an important medical disposition, and a licensed medical professional has the authority to award this medical privilege to the patient (please note that I am not using the term “competence” as this is a legal term and normally is only granted through judicial fiat). Medical decisional capacity is honored if the patient 1) understands the germane medical information, 2) is able to explain the medical information, and 3) is able to make a decision after considering all of the perspectives. By employing these aspects of mental function, the patient should have the ability to engage the decision-making process to the important plateau of being allowed to make decisions regarding his healthcare and future treatment goals. This is a very important part of the medical process, and the patient has the right to accept or reject (even life-sustaining) treatment plans. Furthermore, there are times where the patient should not be granted decision-making authority; this situation typically occurs when the patient has difficulty grasping the medical information. If the patient 1) cannot understand the medical information or 2) is unable to mentally overlay the medical aspect into his social-physical environment (for example, a stroke victim wishes to be discharged but
refuses to allow the physical therapist into his hospital room), then he is not exhibiting the mental faculties necessary for competent decision making. Another important consideration of mental function and decision making is that various types of medical problems demand different levels of mental sophistication. For example, the mental comprehension necessary to make a decision regarding organ transplantation is far greater than that necessary to appoint a healthcare proxy. To that end, an individual with a permanent mental deficiency may be granted the decision-making authority to appoint an agent for their healthcare decisions, but may not be granted the privilege to make a more complicated healthcare decisions. Whereas this determination may be made at the clinical level, sometimes judicial proceedings are necessary.
situation where the availability and use of the medical information is definitely a greater good for a larger population of people. The obvious ethical problem is that authority must be granted — or perhaps even deemed — to make this determination and effect the proposition. In addition, once done, can assurances be made regarding the protective mechanism of PMI that is not appropriate or necessary for public scrutiny?
INFORMED CONSENT: PRIVACY RIGHTS
Note: The CMDA Ethics Committee is developing an ethics statement regarding Informed Consent, and will also give consideration to a statement regarding Privacy Rights in Healthcare.
The primary issue regarding privacy rights is that of disclosure of private and personal medical information (PMI). The initial primary concern of HIPAA was the PMI in the form of office notes, medical conversations, and laboratory data. Hospitals and doctors’ offices have gone to great length and expense to codify and follow the HIPAA rules, and stand in violation if a sincere intended effort is not made and adhered to. Written case reports submitted to medical journals now have no specifically-identifiable features that may break confidentiality, and some specialists have even marked their written consultations with the caveat that the report may not be forwarded without the written permission of the specialist. However, given all of this effort to protect PMI, we are likely approaching (if not already in) a cultural setting that has evolved beyond these protections. Society is likely not too far from a “Gattica”-like setting where saliva, urine, hair follicles, and sloughed skin cells may become part of the public domain where DNA markers can be identified and catalogued. One of the primary issues regarding privacy rights and PMI is the intention behind the proposed use of the medical information and data. If the information is going to be used for detrimental purposes to the individual or society — for example, discrimination in employment or insurance — then the information should and must be held private and protected. However, such protections may not necessarily be appropriate if the information is to be used for laudable public studies such as medical records research (in search of affiliated medical conditions) or public health investigations (outbreaks of infectious diseases). The focus of this paradigm would be different from the individual control of information through informed consent and the protection offered by meaningful privacy and security safeguards. Some argue that this would fall under a utilitarian
SUMMARY: Informed Consent is an important part of healthcare decision-making. Good communication reflecting respect for the patient and veracity of the medical information is a key component in this aspect of the doctor-patient relationship. ✝
REFERENCES: Gostin, LO, “Privacy: Rethinking Health Information Technology and Informed Consent” Connecting American Values with Health Reform (The Hastings Center, 2009): 15-17. Moulton, B, JS King. “Aligning Ethics with Medical Decision-Making: The Quest for the Informed Patient Choices” Journal of Law, Medicine, & Ethics (Spring 2010): 85-96. Thobaben, JR, Health-Care Ethics: A Comprehensive Christian Resource. Downers Grove: IVP Academic, 2009.
Nick Yates, MD, MA (Bioethics), is Professor of Clinical Pediatrics at the State University of New York at Buffalo, and is Adjunct Professor of Bioethics at Trinity International University. He is a member of the Executive Committee for the Section on Bioethics for the American Academy of Pediatrics. He also serves as the Chairman for the Ethics Committee for the Christian Medical & Dental Associations and is the Co-chair of the Healthcare Ethics Council at the Center for Bioethics and Human Dignity.
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CLASSIFIEDS Orofacial Pain and Dental Sleep Medicine – Woodlands, TX – Seeking full-time associate who has a passion for OFP or DSM. Beautiful community 30 minutes from downtown Houston. Visit us at: www.tmjtexas.com for further information. Contact me at: rprehn@tmjtexas.com.
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Medical
Dentist – Philadelphia, PA – Esperanza is a Christian community health center seeking a dentist to perform the full scope of dentistry in our practice. Please submit CV to: resumes@esperanzahealth.com or contact Richard Rohrer at 215-807-8616.
Overseas Missions Seeking Family Medicine Obstetrics Physician desiring expansion of skills for mission hospital activities. Established fellowship program for development of skills in OB/Gyn ultrasound, office surgery, and Spanish. Modules are available on Cesareans, EMR, digital xray, and others. Accepting applications for faculty and fellows. Send CV and goals to: wmrodney@aol.com.
Dentist – Associate for a general and pediatric dental practice located in Concord, New Hampshire. The mountains and the ocean are only 90 minutes away as well as historic Boston. Group strives to make their practice of dentistry an extension of their faith. Contact: grace.family.dentistry@comcast.net. See our online ad on CMDA’s website (www.cmda.org) under Classified Ads for more information.
Positions Open Family Medicine – Family Practice Physician needed for practice in Chatham, Illinois – www.pgaclinic.com. Location has 3 FPs, looking for 4th to share office and hospital rounds. Fax resume and contact information to: 217-391-0392.
A CHRISTIAN LEGACY IN PSYCHIATRY This 3-CD audio series features interviews with Armand Nicholi, MD; Dan Blazer, MD, PhD; William Wilson, MD; James Mallory, MD; and Louis McBurney, MD. Each of these physicians has been a mentor to many — none started out wanting to be a psychiatrist. Their journeys to psychiatry are unique, with unexpected twists and turns. In this series you will learn what factors shaped their careers and practice styles.
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To order Volume 1, 3-CD Series call Dr. Alan Nelson at 970-963-1588 or e-mail: redstonedoc@gmail.com $40 for those in practice $25 for residents and students
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T o d a y ’s C h r i s t i a n D o c t o r
General Surgery – An independent 5-physician group in Charlotte, NC is seeking a young associate. Laparoscopic, bariatric and surgical oncology focus of practice. No trauma or vascular cases. Short-term mission opportunities available. Visit Website at: carolinasurgical.com. Contact Practice Administrator Jacque Greenway at: 704-409-2065. Internal Medicine – Hospital and Office Practice Multispecialty group in Springfield, Illinois seeks full time MD for split practice with equal concentration in hospital and office. www.pgaclinic.com. Fax resume and contact information to: 217-391-0392. Orthopedics – “Do right, love mercy, walk humbly.” – Micah 6:8. Do you share this intent? Ours is a 35+ year old practice devoted to these guiding principles. We aim to help people through our professional and compassionate care as well as our outreach to the community and beyond. Find your niche in an environment that is familyfriendly, community-focused and patientcentric. Low malpractice and cost of living,
A Great Value! CMDA members receive 50% off of classified advertising and 30% off of display advertising in Today’s Christian Doctor. Additional web advertising is minimal cost. Contact Margie Shealy: 423-844-1000 or communications@cmda.org.
on-site surgery center, mission minded, vibrant community with a university, new physician-managed surgical hospital opening in mid-2011, great schools, low crime rate, and lots of ways to make a difference. We want to add at least one other general orthopedist as well as a sub-specialist. Won’t you contact us? Kearney Orthopedic & Sports Medicine, Kearney, NE; Medical Director, Dr. Chris Wilkinson at: 308-6274664 or cwilkinson@kearneyortho.com. Our Administrator, Vicki Aten, at 308-8652512 or vaten@kearneyortho.com. Pediatrician – “. . . My hope is in Him . . .” – Psalm 62:5 Hope Pediatrics was founded in 1999 based on this scripture and His vision for this practice. We are currently seeking a third physician to join our practice located in rural Western Pennsylvania between Pittsburgh and Erie. We aim to provide Christ-centered, comprehensive, compassionate medical care to children here and around the world. Four season community features biking and hiking trails, fishing and hunting. Low cost of living, good private and public schools, low crime rate and many opportunities to make a difference. This would be an employee position with great benefits and opportunities for profit sharing and ownership. One hospital with 1 in 3 to 1 in 5 call coverage. Interest can be directed to our office manager, Lori Ray, via e-mail at: lray@hopepediatrics.com or by calling 814-677-3717. Pediatrician – Successful and rapidly-growing independent pediatric practice in suburban Illinois community near St. Louis seeking Christian pediatrician. Currently 1 pediatrician and 1 mid-level provider. Friendly work environment. Excellent community to raise family. Competitive salary/benefits. Please call: 618-288-9305 or fax curriculum vitae to: 618-288-9308.
The difference between Cosamin® and other joint health supplements is black and white.
There is no gray when it comes to your patient’s health.
Recommend the Best. Recommend Cosamin, The Premier Joint Health Supplement Cosamin is the #1 Recommended Brand of Glucosamine/Chondroitin Sulfate by Orthopedic Specialists.V Ask about our studies and our quality. Get your patients started on CosaminASU— call 1.877.COSAMIN or visit DrStartCosamin.com. Cosamin joint health supplements are developed and manufactured by Nutramax Laboratories, Inc. V
Source: SLACK Incorporated Market Research Survey, April 2009. Survey conducted of Orthopedic Specialists relating to glucosamine/ chondroitin sulfate brands.
CHRISTIAN MEDICAL & DENTAL ASSoCIATIoNS P.o. Box 7500 Bristol, TN 37621-7500
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