Friday, December 31, 2010

The Wall Street Journal Weighs In about St. Joseph's Hospital

I've been following the controversy between Bishop Olmsted of the Phoenix Diocese and St. Joseph's Hospital in Phoenix and its parent organization, Catholic Healthcare West. (See here, here, and here for previous posts.) I'm not Catholic, but I"m moved by the moral seriousness of Catholic healthcare ethics, and have admired the church's strong traditions of social justice since learning about the Berrigan brothers during the Vietnam era.

In an op ed in today's Wall Street Journal, Professor Anne Henderschott of The King's College in New York weighs in with strong support of the Bishop. I've taken the liberty of reprinting the op ed, with my own comments interlaced in bold italics:
Catholic Hospitals vs. the Bishops
Administrators shop for theologians to support practices that conflict with church teachings

The severing of ties last week between the Catholic Church and St. Joseph's Hospital in Phoenix, Ariz., is the latest example of the fraying relationship between the bishops and Catholic hospital administrators. In recent years, some Catholic hospitals have taken greater liberties, authorizing abortions and sterilization procedures that the church strictly prohibits. Earlier this year, for instance, Rev. Robert Vasa, bishop of the Diocese of Baker, Ore., ended the church's sponsorship of St. Charles Medical Center in Bend over the hospital's performance of tubal ligations.

But the Phoenix case breaks new ground. In explaining his decision, Rev. Thomas Olmsted, bishop of the Phoenix Diocese, was the first to explicitly point to the role played by Catholic theologians in providing theological cover for "a litany of practices in direct conflict with Catholic teachings."

The terms "shop for theologians" and "theological cover" are catchy journalism, but cheap shots of this kind are demeaning to what has thus far been a thoughtful, respectful deliberation. The terms presuppose the correctness of the Bishop's position, which is exactly what is being questioned.

The break began more than a year ago, when a Catholic nun and longtime administrator of St. Joseph's Hospital gave permission for doctors to perform an abortion. She claimed the pregnancy was terminated to save the life of the mother. Sister Margaret McBride's decision drew sharp criticism from Bishop Olmsted. After excommunicating Sister McBride, the head of the diocese then turned his attention to the role of the hospital itself.

In the phrase "She claimed..." the op ed again substitutes rhetoric for analysis. "Claim" is defined as "demanding one's due." Guilty parties claim innocence. Children claim the toy is really theirs and doesn't belong to the true owner. A proper description is that Sister Margaret "concluded" that the procedure was morally justified. We might end up thinking she was wrong, but we shouldn't treat her as making an unreasoned "claim."

In a Nov. 22 letter to Lloyd H. Dean, president of Catholic Healthcare West, the hospital's parent company, Bishop Olmsted wrote that he would be moving to revoke the Catholic status of the hospital unless certain conditions were met by hospital administrators. Among other things, the bishop demanded that hospital officials acknowledge in writing that the abortion performed was a violation of Catholic directives for health-care institutions.

But hospital officials have defied the bishop and refused to meet his conditions. Rather than acknowledge that an illicit abortion had been performed at his hospital, Mr. Dean attempted to support Sister McBride's decision by pointing out that "many knowledgeable moral theologians have reviewed this case and reached a range of conclusions."

Once again, the op ed assumes that the procedure was "an illicit abortion" without engaging with the substantive questions at stake.

In a July 6 letter to Bishop Olmsted, Mr. Dean asserted that "this is a complex matter on which the best minds disagree." Citing the opinion of Marquette University Professor M. Therese Lysaught on the permissibility of the abortion performed at St. Joseph's, Mr. Dean appeared to suggest that the teaching authority of the Phoenix Bishop was just one more "opinion" on a "complex matter."

I've had the opportunity to read Professor Lysaught's analysis. In its careful attention to (a) the medical facts of the situation and (b) the complex ethical issues the patient, family, and caretakers were dealing with, it's (c) a brilliant, persuasive analysis. I hope it becomes widely available - I would like to use it in my class on medical ethics as an example of careful reasoning about a topic that is too often drowned in strident rhetoric.

This case points to the real problem in the church. For too long, the authority of bishops has been limited to issuing mere opinions. This is especially true at Catholic colleges and universities, where bishops have little affect on the culture and curriculum.

In the recent health-care debate, it was these same Catholic theologians who joined Sister Carol Keehan, head of the Catholic Health Association, to defy the bishops over the legislation in Congress. Cardinal Francis George, president of the United States Conference of Catholic Bishops, criticized Sister Keehan and her organization for supporting a bill that did not contain provisions to protect life. President Obama was so grateful for Sister Keehan's help in shepherding the bill through Congress that he awarded her one of the 20 pens used in the law's signing ceremony at the White House.

Many theologians, like Prof. Nicholas Healy of St. John's University in New York, write that theologians comprise "an alternative magisterium" to the teaching authority of the bishops. And in cases like the one at St. Joseph's, the alternative magisterium often trumps the true Magisterium of the church. Catholic colleges and hospital administrators now "shop" for theologians who will support their decisions.

As an interested observer of the Catholic tradition, my hunch is that the choice for the church is finding ways to live with the "alternative magisterium" or lose Catholics to other denominations (or to "unaffiliated" status). As I've written in a previous post, the Bishop's conclusion about the Phoenix case is not likely to persuade many of the faithful. The fetus and mother were both in the process of dying. There was no medically imaginable scenario that would have led to birth of a living child. The Bishop's position would appear to have required the caretakers to wait until the fetus had died, hoping that the mother would still be alive and that a D & C could then be done to save her life. Even to those who regard abortion as an evil to be forbidden, I believe the Bishop's position will seem like a tortured effort to hold to an orthodoxy that simply makes no sense by criteria of (a) "common sense," but also (b) by Catholic theology and ethics, seen in the light of Professor Lysaught's analysis.

Bishop Olmsted has refused to allow this to continue. In his letter responding to Mr. Dean, the bishop wrote: "You have only provided opinions of ethicists that agree with your own opinion and disagree with mine."

Concluding that "there can be no tie so to speak in this debate," Bishop Olmsted said, "it is my duty as the chief shepherd in the diocese to interpret whether the actions at St. Joseph's meet the criteria of fulfilling the parameters of the moral law as seen in the Ethical and Religious Directives."

For faithful Catholics, there is relief that the tie between the theologians, the administrators and the bishops seems finally to have been broken. But there remains a sadness that yet another Catholic institution has been lost.

I have no expertise about the theological understanding of the role of the Bishop within the church, but I believe Bishop Olmsted is correct in claiming positional authority to declare what is true church teaching. The problem with regard to the St. Joseph's Hospital situation is that his analysis is not likely to be persuasive. Since the fetus, as well as the mother, was in the process of dying, there was no way to protect the unborn life. The choice was between two deaths, or one.
The comments in response to newspaper articles on the case often invoke the pedophile scandals. This is psychologically understandable, but not relevant to the merits of the Bishop's argument. The pedophile scandals have dealt a severe blow to trust in the church heirarchy, just as the scandals about sex with patients and corruption of medical judgment by commercial interests have diminished trust in the medical profession. Trust is easy to lose and very difficult to regain.

In a previous post I encouraged readers to watch the press conference in which Bishop Olmsted explained his decision. Although I was not impressed by his reasoning, I was moved by his moral passion, as expressed in his response to a question he was asked about being vilified in the media:
I really don’t read the blogosphere. I try to pray each day to find my identity in Jesus Christ… My identity comes from Christ. Christ is present in his living body, the church… That’s my identity, it comes from there. If I am unfaithful to that, then whether I’m looked at one way or another, if I’m given praise or given ridicule doesn’t matter. What I’m called to be is faithful to Jesus Christ and his church.
To my reading, paragraph 47 in the Ethical and Religious Directives for Catholic Health Care Services exactly describes the situation the patient, family, and caretakers faced:
Operations, treatments, and medications that have as their direct purpose the cure of a proportionately serious pathological condition of a pregnant woman are permitted when they cannot be safely postponed until the unborn child is viable, even if they will result in the death of the unborn child.
Had the caretakers postponed the intervention they made, both mother and fetus would have died. In concluding that it was ethically and theologically correct to terminate the pregnancy the patient, family, and caretakers were acting in accord with Jesus's teaching "I was sick, and ye visited me." I was sad to see Bishop Olmsted attach his moral passion to a conclusion that appears to be erroneous within his own theological and ethical tradition.

Friday, December 24, 2010

In Praise of St. Joseph's Hospital and the Sisters of Mercy

Although I believe that Bishop Olmsted was wrong from the perspectives of both secular and Catholic medical ethics when he decreed that St. Joseph's Hospital "no longer qualifies as a 'Catholic' entity...[and] may not use the name Catholic or be identified as Catholic in the Diocese of Phoenix," the moral seriousness and dignity of the conflict has much to teach. (See here and here for previous posts on the topic.)

Here's how St. Joseph's Hospital explained its views about the clinical circumstances:
A woman in her 20’s with a history of moderate but well-controlled pulmonary hypertension found out she was pregnant. There was concern for her health, because pregnancy with pulmonary hypertension carries a serious risk of mortality. Because of the severity of her disease, the woman’s risk of mortality was close to 50 percent. In November 2009, the woman was admitted to St. Joseph’s Hospital and Medical Center with worsening symptoms. Tests revealed that she now had life threatening pulmonary hypertension. The chart notes that she had been informed that her risk of mortality was close to 100% if she continued the pregnancy. The medical team contacted the Ethics Consult team for review. The consultation team talked to several physicians and nurses as well as reviewed the patient’s record. The patient and her family, her doctors, and the Ethics Consult team, agreed that the pregnancy could be terminated, and that it was appropriate since the goal was not to end the pregnancy but save the mother’s life.
The Bishop's condemnation and St. Joseph's defense both draw on a component of Catholic tradition that I, a non-Catholic, especially admire - the preferential option for the poor and vulnerable. This commitment to social justice comes from Jesus, as in this passage about the last judgment from Matthew (King James version):
34 Then shall the King say unto them on his right hand, Come, ye blessed of my Father, inherit the kingdom prepared for you from the foundation of the world:

35 for I was ahungered, and ye gave me meat: I was thirsty, and ye gave me drink: I was a stranger, and ye took me in:

36 naked, and ye clothed me: I was sick, and ye visited me: I was in prison, and ye came unto me.

37 Then shall the righteous answer him, saying, Lord, when saw we thee ahungered, and fed thee? or thirsty, and gave thee drink?

38 When saw we thee a stranger, and took thee in? or naked, and clothed thee?

39 Or when saw we thee sick, or in prison, and came unto thee?

40 And the King shall answer and say unto them, Verily I say unto you, Inasmuch as ye have done it unto one of the least of these my brethren, ye have done it unto me.
I encourage readers to watch the press conference in which Bishop Olmsted explained his decision. Although I was not impressed by his reasoning, I was moved by his moral passion. Here's the Bishop's response to a question he was asked about being vilified in the media:
I really don’t read the blogosphere. I try to pray each day to find my identity in Jesus Christ… My identity comes from Christ. Christ is present in his living body, the church… That’s my identity, it comes from there. If I am unfaithful to that, then whether I’m looked at one way or another, if I’m given praise or given ridicule doesn’t matter. What I’m called to be is faithful to Jesus Christ and his church.
The Bishop sees himself as defending the vulnerable fetus, since the life-saving intervention used the same medical technique that is applied in most abortions. What he fails to recognize, however, is that the fetus was not simply vulnerable - it was in the process of dying. The choice the family and the caretakers faced was whether to stand by and let the mother die as well, or terminate the pregnancy, which gave the mother a chance to live. There was no scenario by which the fetus would become a living child.

I'm in no way expert on Catholic medical ethics, but to my reading paragraph 47 in the Ethical and Religious Directives for Catholic Health Care Services exactly describes the situation the patient, family, and caretakers faced:
Operations, treatments, and medications that have as their direct purpose the cure of a proportionately serious pathological condition of a pregnant woman are permitted when they cannot be safely postponed until the unborn child is viable, even if they will result in the death of the unborn child.
Had the caretakers postponed the intervention they made, both mother and fetus would have died. In concluding that it was ethically and theologically correct to terminate the pregnancy the patient, family, and caretakers were acting in accord with Jesus's teaching "I was sick, and ye visited me." I am sad to see Bishop Olmsted attach his moral passion to a conclusion that appears to be erroneous within his own theological and ethical tradition.

Wednesday, December 22, 2010

A Worthy Conflict about Abortion in Arizona

The level of public debate about health care ethics has been in a sorry state in recent years, as evidenced by the Kaiser Family Foundation finding that thirty percent of seniors still believe the health reform law lets a government panel ("death panel") make decisions about end of life care.

In contrast, the Arizona "theological showdown" over abortion that I posted about last week addresses profound ethical issues with admirable clarity.

In November 2009 St. Joseph's Hospital in Phoenix performed an abortion on a patient who was (a) 11 weeks pregnant and (b) terminally ill with pulmonary hypertension, a condition made much worse by pregnancy. The hospital concluded it could not save both mother and gestating child. After consultation with patient, family, caregivers, and ethics committee, the abortion was performed.

Bishop Olmsted demanded that St. Joseph's acknowledge by December 21 that it had violated ethics and Catholic teachings and promise never to repeat what it had done. The hospital refused. In a terse statement the Bishop concluded that St. Joseph's "no longer qualifies as a 'Catholic' entity...[and] may not use the name Catholic or be identified as Catholic in the Diocese of Phoenix."

St. Joseph's response was respectful, but firm:
The leadership of St. Joseph's Hospital and Medical Center in Phoenix is saddened today following Bishop Thomas Olmsted's announcement that he has revoked his endorsement of the hospital as "Catholic." At his direction, the hospital will remove the Blessed Sacrament from the chapel and will no longer celebrate mass there.

Though we are deeply disappointed...St. Joseph's will remain faithful to our mission of care, as we have for the last 115 years...[we] will continue through our words and deeds to carry out the healing ministry of Jesus.

Consistent with our values of dignity and justice, if we are presented with a situation in which a pregnancy threatens a woman's life, our first priority is to save both patients. If that is not possible we will always save the life we can save, and that is what we did in this case...Morally, ethically, and legally we simply cannot stand by and let someone die whose life we might be able to save.
In teaching medical ethics I always encourage the groups I work with to (a) think through what they believe is the right thing to do, (b) explain the rationale for their conclusion, and then (c) ask what the law says. Most of the time law and ethics will coincide.

If our ethical analysis and the requirements of law diverge, the first thing to do is to revisit our ethical analysis. Did we miss something? After all, law is an expression of the body politic's conclusions about how to govern itself.

If we hold to the conclusion we reached, the next question is whether we see the situation as one in which fair-minded people can disagree about right and wrong. The Bishop spoke to this in his November letter to Catholic Healthcare West, parent organization to St. Joseph's: stated in a letter to me "As you know, many knowledgeable moral theologians have reviewed this case, and reached a range of conclusions. If we may assume that these individuals are motivated by their faith and desire for justice, one must at least acknowledge that this is a very complex matter, on which the best minds disagree." Thus, it would appear that your intention is to resolve our disagreement by asserting that there is no single "correct" answer to the question of whether the procedure that led to an abortion at St. Joseph's Hospital was morally permissable under the Ethical and Religious Directives of the USCCB. In effect, you would have me believe that we will merely have to agree to disagree. But this resolution is unacceptable because it disregards my authority and responsibility to interpret the moral law and to teach the Catholic faith as a Successor to the Apostles.
Catholic Healthcare West and St. Joseph's Hospital believe their interpretation of the moral law taught by the Catholic Church is correct. The Bishop claims that his position in the Church heirarchy gives him authority to decree the correct answer. It appears that Catholic Healthcare West and St. Joseph's believe that he is not infallible and has, in fact, reached a conclusion they regard as wrong and cannot accept.

To the best of my knowledge, the Bishop's claim that he has authority to decree what the correct answer to the St. Joseph's question is correct under Cannon law. But this "authority" is not persuasive to his flock - a 2009 Gallup poll showed that forty percent of Catholics regard abortion as morally acceptable. Insofar as the Phoenix case draws attention within the Church, the Bishop's action is likely to push more Catholics away from the official teaching, given that this was a situation in which holding to the official position meant death for the mother. The hospital accepted the Bishop's authority to take away their right to say Mass in the chapel, but claim the authority of Jesus himself to justify their conclusion about the ethical course.

Thursday, December 16, 2010

Theological Showdown over Abortion in Arizona

Bishop Thomas J. Olmsted, the Catholic Bishop of Phoenix, has thrown down a theological gauntlet to St. Joseph's hospital. If the hospital does not acknowledge that he was right in his condemnation of a medical procedure that involved abortion he will revoke it's status as a Catholic hospital.

The story goes back to November 2009. All that is publicly known is that a patient at the hospital (1) had pulmonary hypertension, (2) was pregnant, a combination associated with a high rate of fatality, and that (3) Sister Margaret McBride, vice president of mission, was a member of the hospital ethics committee that was consulted about the case.

On May 14, 2010, Bishop Olmsted made the following statement:
I am gravely concerned by the fact that an abortion was performed several months ago in a Catholic hospital in this Diocese. I am further concerned by the hospital's statement that the termination of a human life was necessary to treat the mother's underlying medical condition.

An unborn child is not a disease. While medical professionals should certainly try to save a pregnant mother's life, the means by which they do it can never be by directly killing her unborn child. The end does not justify the means.

Every Catholic institution is obliged to defend human life at all its stages; from conception to natural death. This obligation is also placed upon every Catholic individual. If a Catholic formally cooperates in the procurement of an abortion, they are automatically excommunicated by that action. The Catholic Church will continue to defend life and proclaim the evil of abortion without compromise, and must act to correct even her own members if they fail in this duty.

We always must remember that when a difficult medical situation involves a pregnant woman, there are two patients in need of treatment and care; not merely one. The unborn child's life is just as sacred as the mother's life, and neither life can be preferred over the other. A woman is rightly called 'mother' upon the moment of conception and throughout her entire pregnancy is considered to be 'with child.'

The direct killing of an unborn child is always immoral, no matter the circumstances, and it cannot be permitted in any institution that claims to be authentically Catholic.

As our late Holy Father, Pope John Paul II, solemnly taught in his encyclical 'The Gospel of Life,' a 'direct abortion, that is, abortion willed as an end or as a means, always constitutes a grave moral disorder, since it is the deliberate killing of an innocent human being' (The Gospel of Life #62).

The Ethical and Religious Directives for Catholic Healthcare Institutions (ERDs) are very clear on this issue: 'Catholic health care ministry witnesses to the sanctity of life from the moment of conception until death. The Church's defense of life encompasses the unborn and the care of women and their children during and after pregnancy.' (ERD, Part Four, Introduction) The ERDs further state that 'Abortion (that is, the directly intended termination of pregnancy before viability or the directly intended destruction of a viable fetus) is never permitted. Every procedure whose sole immediate effect is the termination of pregnancy before viability is an abortion.(ERD 45)"
Here's the statement St. Joseph's hospital had made:
At St. Joseph's Hospital and Medical Center, our highly-skilled clinical professionals face life and death decisions every day. Those decisions are guided by our values of dignity, justice and respect, and the belief that all life is sacred.

We have always adhered to the Ethical and Religious Directives for Catholic Health Care Services as we carry out our healing ministry and we continue to abide by them. As the preamble to the Directives notes, 'While providing standards and guidance, the Directives do not cover in detail all the complex issues that confront Catholic health care today.'

In those instances where the Directives do not explicitly address a clinical situation - such as when a pregnancy threatens a woman's life - an Ethics Committee is convened to help our caregivers and their patients make the most life-affirming decision.

In this tragic case, the treatment necessary to save the mother's life required the termination of an 11-week pregnancy. This decision was made after consultation with the patient, her family, her physicians, and in consultation with the Ethics Committee, of which Sr. Margaret McBride is a member.
In a subsequent interview Suzanne Pfister, vice president of communications for the hospital, added: "We believe that all life is sacred. In this case, we saved the only life we could save, which was the mother's."

On November 22 Bishop Olmsted sent a remarkable four page letter to Lloyd Dean, president of Catholic Healthcare West, the large not-for-profit system with 40 hospitals - including St. Joseph's - in Arizona, California and Nevada. (The letter was made available to, i.e., leaked to, and published by, the Arizona Republic.)

The Bishop quotes from a letter from Catholic Healthcare West as saying "many knowledgeable theologians have reviewed the case, and reached a range of conclusions. If we assume that these individuals are motivated by their faith and desire for justice, one must at least acknowledge that this is a very complex matter, on which the best minds disagree."

The Bishop will have none of it. Here's his response - "There cannot be a tie in this debate. Until this point in time, you have not acknowledged my authority to settle this question. Your actions communicate to me that you do not respect my authority to authentically teach and interpret moral law in this diocese. Failure to fulfill these requirements will lead me to decree the suspension of my endorsement of St. Joseph's Hospital, forcing me to notify the Catholic faithful that St. Joseph's Hospital no longer qualifies as a Catholic hospital..." He gives Catholic Healthcare West until Friday December 17 to capitulate by acknowledging in writing that they have made a grave error and that he is correct.

I do not know the particulars of the clinical situation, but from the Bishop's letter I infer that the patient's physicians concluded that there was no way to save the lives of both mother and baby-to-be. The choice was two deaths, or one.

The Bishop is correct that Canon Law decrees him to be the "decider." But if I am correct in my inference about the clinical facts, he will not be regarded - including by many Catholics - as having moral, as opposed to legal, authority. He will not be seen as a true arbiter of what is right in the situation.

(See here and here for two excellent articles by Michael Clancy in the Arizona Republic. The second article has a brief quotation from me - I'm grateful to Mike for contacting me about the situation.)

Tuesday, December 14, 2010

Judge Hudson's Monstrous Decision

Judge Hudson's ruling yesterday in the Federal District Court in Richmond that the insurance mandate is an assault on liberty is a moral monstrosity.

His decision reflects the same terror about government encroachment on individual liberty that drives the Tea Party movement. In October the judge had commented that the insurance mandate sets a "boundless" precedent for government control that could lead to forcing individuals "to buy an automobile, to join a gym, to eat asparagus." The absurdity of his comment reflects the intensity of his fear.

Anyone who knows anything about health care understands that the U.S. has two - and only two - ethically acceptable choices. We can go with a Rube Goldberg scheme like the Affordable Care Act, in order to cover (almost) everyone while avoiding a single payer system, or, as a majority of health professionals would support, take the route of single payer. Paradoxically, by yielding to his fear of asparagus, Judge Hudson makes it likelier that the U.S. will end up with the option conservatives fear most!

There is, however, one more choice - the monstrous one that Judge Hudson's ideologically driven folly points towards. Each of us can be given the "liberty" to be uninsured until leukemia or a motor vehicle accident hit us. At that point, our fellow citizens can exercise their liberty to say "it was your free choice - live, or rather, die, with the consequences."

But as much as I believe that Judge Hudson's decision is erroneous law and monstrous ethics, he teaches an important lesson to those who, like me, endorse a more communitarian ethical perspective. Liberty is truly our country's guiding spirit. The Tea Party (and asparagus-fearing judges) are vigilant in defending "liberty from" tyranny. But the rest of us haven't made an effective case about the other founding principle in our Declaration of Independence and Constitution - "liberty to" pursue happiness.

Our liberty to pursue happiness is meaningless without health.

Judge Hudson's sound bite rhetoric about an asparagus conspiracy is 100% consistent with the Founders' commitment (in the Declaration of Independence) to maximum individual liberty. But it's 100% inconsistent with their commitment (in the Constitution) to promote the general Welfare, and secure the Blessings of Liberty to ourselves and our Posterity."

Wednesday, December 8, 2010

Christmas Tree Ethics

My friend and colleague Steve Moffic, gave me permission to quote this holiday season post from "Behavioral Healthcare."
A Multicultural Holiday Display

At first, I was tempted to just comment on the provocative blog, “Can Christmas Decorations Be Psychologically Harmful?”, posted by Terry Stawar here on November 30. I would have commented that yes, they can be psychologically harmful, both to an individual, but also to a group of people. And, unlike Ben Stein (who was referenced in that blog and who I generally admire), I as a Jew would be one of those offended if that was done in my work setting. Indeed, it is our work settings that I especially want to address.

To address this kind of question and challenge to the multicultural nature of our country, our staff, and our patients, the clinics I have led over the years have long held a multicultural holiday display during a good part of December. This tradition was started when I co-led a large community mental health center with an African-American woman. This has always – and still does – include the Muslim perspective, along with Christian, Jewish, Hindu, and any other religious or cultural perspective we can reflect, such as Kwanzaa and the Hmong New Year. Traditional cultural dress is encouraged.

The display not only includes holiday symbols like a small Christmas tree and Hanukah menorah, but also food for the patients. This is food that the staff brings in, such as the usual Christmas cookies. I usually bring in Hanukah donuts, called Sufganiyot in Israel. These are usually raspberry filled donuts fried in oil to represent the oil that miraculously burned for 8 days in the ancient temple of Jerusalem, after the Maccabean revolt restored our freedom of religion. In the USA, reasonable representatives can be bought at Dunkin Donuts. All this is supplemented by simple educational handouts about the holidays and cultures.

Why might this be important, even beyond the holiday time? Any system or clinic that purports to have cultural competence needs, at the very least – to be culturally sensitive and respectful – of all the cultures served. This should also be displayed in the treatment plans tailored to the patient’s cultural beliefs. Holiday displays are one way to show that to everyone.

What does your organization display, or not display, during this season? And why?
In consulting with health organizations about ethics and strategy, I'm often asked about the concept of "ethics culture." In my view, culture wins hands down over mission/vision statements, formal strategy, and codes of conduct as a driver of patients' experience of care. Steve's comments connect nicely to this issue.

I often quote Albert Schweitzer's wise aphorism: "example is not the main thing in influencing others; it is the only thing." For those associated with a health organization as employees or independent contractors (like doctors in relation to a hospital), the organization sets the "example" through its culture, which is itself created by hundreds, probably thousands, of actions.

As an example of culture running amok, watch the video of "Enron: The Smartest Guys in the Room" if you haven't already seen it.

Culture emerges from patterns. If the kind of holiday recognition Steve describes so nicely is consistent with other behaviors showing respect for diversity and taking pleasure in human variety, the organization will evince cultural competence. But if respect and curiosity aren't a way of life for the organization, the same holiday practices could evoke cynicism.

Malpractice lawyers teach that patients and families are less likely to sue after bad outcomes in the context of a good patient-doctor relationship. Organizational culture is like the clinical relationship writ large. When it's positive we forgive the inevitable frustrations that occur. We're likelier to fix problems and not hunker down with bitterness. These alternative reactions affect patient care.

The bottom line is that we should take the spirit that infuses the holiday practices Steve describes and apply it throughout the year!

Sunday, December 5, 2010

Doctor-Patient Sex in ObGyn Care

I decided to reply to a comment that just came in about a post I wrote on doctor-patient sex in 2009 in a new post. The topic has drawn a lot of interest, and I didn't want the comment and my response to get buried in the past. Here's the comment from "Anonymous":
My obgyn has been pretty much my primary care physician for the last 12 years. He delivered my son 3 years ago. He has always had a great bed-side manner and made me me feel like I was the most important patient. I had always thought this was a great skill that he was able to make all his patients feel this way. As I look back over the years, comments about my looks, my sex life, and my job as a sex education teacher just seemed like a normal part of the visits. During my last yearly exam he asked me the normal question of what kind of birth control I was using. This question got me talking about the unsatisfactory sex life with my husband...maybe I shared too much and went into too much detail. He started talking about possible solutions that included medication for my husband, toys, positions, and finally said that I may need to get a boyfriend. We were kind of laughing about that. The conversation actually turned into me hitting on him and telling him about my sexual fantasies involving him and the exam table! Still, I really didn't think things had crossed the line. None of this conversation happened with me undressed, but rather after the physical exam. As I was leaving, he gave me a kind of one-armed hug and then turned my face to his and kissed me on the mouth. It was just a peck really, but it was obviously intentional. As he walked me out he told me that I could always call him after 5:00 at the office to speak to him directly.I could not get him off my mind all weekend. I have actually been attracted to him for years, but we have both been married at one time or another. I decided to call on Monday and just talk. We decided to meet on Wednesday at his office and had incredible sex on his office sofa. We have meet two other times over the past month. When we are together, I can't get enough of him. He says and does all the right things. He knows I would never leave my husband; and also knows that I really want to meet with him more often. He is really busy, which I understand, but I feel like I need him much more than he needs me. I have no desire to ruin this man's practice or hurt him in any way, but I feel a little "led on" in that he knew what I was looking for in a "boyfriend" when he volunteered for the job. Any thoughts?
Here's my response:
Dear Anonymous -

Thank you for your thoughtful, candid comment. In response to your closing question, I have a number of thoughts.

My focus in this blog is healthcare ethics, so that's the only dimension of the situation I'll comment on.

Your obgyn's capacity to make each of his patients feel special and important is something every physician should strive for. I can't tell whether in retrospect you believe his manner over the 12 years he's been your doctor was flirtatious and sexually inviting. Comments about looks, sex life, and your work as a sex educator could be an entirely appropriate part of obgyn care, but even if they were made with entirely professional intent (which is, in retrospect, uncertain), the intimacy of obgyn care has great capacity to elicit strong reactions, like the erotic fantasies you experienced. That's why the American College of Obstetricians and Gynecologists code of ethics is unambiguous about doctor-patient sex: "Sexual misconduct on the part of the obstetrician-gynecologist is an abuse of professional power and a violation of patient trust. Sexual contact or a romantic relationship between a physician and a current patient is always unethical."

Your comment that "I feel like I need him much more than he needs me" speaks to one of the dangers in sexual and romantic relationships between doctor-patient. The physician-patient relationship is asymmetrical. Physicians are in a position of "caring authority." That role can elicit what in psychiatry gets called "transference." The professional responsibility of the physician is to understand "transference" and manage both (a) the risks to patients and (b) our own reactions.

The fact that a patient might "hit" on the physician doesn't change a physician's ethical and clinical responsibility. Patients are entitled to express their feelings and fantasies, just as you describe. In a teaching session during my first year of residency a senior psychiatrist told of how a patient expressed a wish for romantic involvement. He responded "it won't be difficult for you to find a boyfriend if you want one, but it isn't so easy to find a good psychiatrist - that's the role you need me to be in."

The code of ethics for psychiatry differs from obgyn in an important detail. I put the key difference into bold italics: "the necessary intensity of the treatment relationship may tend to activate sexual and other needs and fantasies on the part of both patient and psychiatrist, while weakening the objectivity necessary for control. Additionally, the inherent inequality in the doctor-patient relationship may lead to exploitation of the patient. Sexual activity with a current or former patient is unethical." The psychiatric profession has concluded, in my view correctly, that psychiatrists are responsible for continuing to act in a professionally responsible manner after treatment ends.

Your final comment that you "feel a little 'led on'" sounds realistic to the situation as you describe it. I'm concerned that you appear to be experiencing a sense of conflict and perhaps emerging hurt. I would encourage you to consider counselling to deal with the marital unhappiness you've experienced and the relationship that has emerged with your obgyn.

Again, thank you for your thoughtful and important comment!



Wednesday, December 1, 2010

Greedy Geezers vs Granny Bashers

To protect the future of Medicare and contain runaway Medicare costs we need thoughtful deliberation and responsible advocacy.

Instead, what we're getting is a shouting match between "Greedy Geezers" and "Granny Bashers."

Greedy Geezers are the over-65 folks who turned against the Democrats by 21 percent in the November elections, largely fueled by fear that health reform would undermine Medicare. Granny Bashers are the largely under-65 folks who see the Medicare set as selfishly protecting their own federally funded entitlement while refusing to bring others into the insurance tent.

To salvage the economy and protect it over time we have to restrain Medicare costs. But if we go at those costs under the banner of blame, the Greedy Geezers will go to war. (I'm allowed to use the "Greedy Geezer" term since I'm part of the Medicare cohort. I'm talking about "us," not "them.")

James Ridgeway, who writes the progressive "Unsilent Generation" blog "for pissed-off progressive old folks (and future old folks)," tells us what the real problem is. Here's what Ridgeway says in his response to David Brooks's New York Times op ed "The Geezers' Crusade":
Politicians are talking about the urgent need to cut Medicare because Democrats and Republicans alike won’t take on the real enemies of affordable health care: the insurance companies, Big Pharma, and other providers of medicine for profit. They’re saying we have to “reform” Social Security (a program which, compared to Citibank and Goldman Sachs, is a model of financial solvency) because they are unwilling to really take on Wall Street. They’re devising ways to skim off of entitlements, which have lifted millions of old people out of dire poverty, because they won’t consider a more “socialist” tax structure--like, for example, the one we had in the United States during the Nixon Administration.

This fabrication serves a myriad of purposes. It substitutes a phony intergenerational conflict--a phantom battle between young and old--for the real conflict in American society: the conflict between the interests of poor and middle-class people, who pay more than their fair share, and the corporations and wealthy elite, who get an easier ride in America than they do anywhere in the developed world...But hey--why talk about taxing the rich when you can balance the budget on the backs of those Greedy Geezers?
The problem isn't that the Medicare crowd is greedy. Ridgeway is right - it's that cutting Medicare (and social security) doesn't pass the smell test when we read about Wall Street shenanigans. In my 45 years of clinical practice I was impressed with how unselfish my elderly patients were, not with their greed.

Medicare is a superb social program, but it's way too costly for the benefit it provides. Medicare recipients won't join in on a campaign that looks like blaming "Greedy Geezers" for Wall Street's greed. Here's what I see as the three pillars for an advocacy program that progressively minded Medicare recipients could get behind:

  1. Overtreatment. Seniors aren't driving the overly interventionist, overly technological treatment approach that characterizes so much of the Medicare world. It's the combination of the for-profit medical-industrial complex, fee for service reimbursement, and an all-too-common profligate style of practice. At best, overtreatment creates costs without benefit. But commonly it causes injury. Advocating for the right treatment at the right time in the right place, as defined from a patient-centered perspective, is a position many Medicare recipients will support.

  2. Direct costs to the elderly. A just-released Employee Benefit Research Institute report shows just how substantial retirement health care costs are despite insurance. Men retiring this year at age 65 will need anywhere from $65,000–$109,000 in savings to cover health insurance premiums and out-of-pocket expenses in retirement if they want a 50–50 chance of being able to have enough money; to improve the odds to 90 percent, they’ll need between $124,000–$211,000. Women retiring this year at 65 will need between $88,000–$146,000 in savings if they are comfortable with a 50 percent chance of having enough money, and $143,000–$242,000 if they want a 90 percent chance.

    In other words, even though Medicare recipients are the best insured population in the U.S., commercial profiteering and profligate practice styles are driving very substantial out-of-pocket costs. Continued cost escalation will lead to even more cost sharing. Advocating for practices that reduce out-of-pocket costs that provide little or no benefit (or even cause harm) is a position Medicare recipients will support.

  3. If reducing overtreatment and managing the care process in ways that reduce direct costs to the elderly curb overall Medicare expenditures, that will be a positive "side effect." Those who agree with Ridgeway will continue to advocate for progressive economic policies. Those who don't, won't. But reducing overtreatment and direct costs to the elderly won't be seen as blaming Greedy Geezers for the mess we're in. It's an responsible, progressive advocacy position that Medicare recipients can get behind.