In the "It's a Nice Gesture, But . . ." Category

Our winner is: Trinket Round-up Day!

A Minnesota hospital system, eager to show how serious it is about containing drug costs and making prescription decisions based on science alone, has conducted a hospital-wide purge of notebooks, pens, post-it notes, and the like with drug ads on them.

This very admirable gesture netted over 18,000 items, all of which are now banned--that is, doctors are banned from accepting such items as gifts from drug company reps.

One hopes that lavish cruises, expensive dinners, and opulent parties are likewise banned, but such was not specified. In fact, one suspects that drug companies will find ways to "work with the system" (read: work around the system) in order to do what they've always done.

Predictably, a pharmaceutical industry spokesperson called the trinket sweep "Draconian."

But personally, I found the last two lines of the article to be the most telling:

Many of [the hospital's] items will be going to the health system of the Evangelical Lutheran Church of Cameroon, which has three hospitals, and several rural health centers.

Irons said there shouldn't be a conflict of interest in Cameroon because the advertised drugs aren't available there.

Books in Review

The Body in Pain: The Making and Unmaking of the World, by Elaine Scarry, begins with an absolutely brilliant account of the interior structure of torture--how it accomplishes what it intends, what it, in fact, intends quite apart from what it purports to intend, how embodiment is configured in the interaction between torturer and victim.

That we are now having something of a national . . . well, debate is too strong a word, isn't it? . . . thought exercise maybe? (of course, it's only a thought exercise for us) on the subject of torture only makes Scarry's chapter seem eerily prescient (the book was published in the mid-nineties).

She then moves to an equally important reading of the structure of war. Following Carl von Clausewitz, she makes the simple (but hardly simplistic) statement that war is an injuring contest whose physical consequences are held to certify the right of the "winner" to author reality for both parties. Each aspect of that statement (injuring, contest, consequences, winning, authoring reality) receives thorough attention, especially to the ways in which the statement's accuracy is masked (whether intentionally or incidentally) in speech about war (histories, media reports, propaganda, personal accounts).

My respect for Scarry's accomplishment in these two chapters is only partially mitigated by the three chapters that follow. The conceptual lenses by which she is able to read war and torture (and later, capitalism) so keenly are themselves less persuasively described.

For Scarry, bodily pain is the ground of creation/civilization and disembodiment is its product. One makes--coats, bread, speech, ideas--in order to alleviate an uncomfortable awareness of one's body (hunger, vulnerability to injury). The made thing, as long as it perdures, gives benefits the force of which is to remake the body of the maker (resistance to cold, increased mobility, ability to communicate with those outside the range of one's physical capacity) in a manner that disguises the limits imposed by human embodiment.

While this analysis has much to recommend it, Scarry's account of pain and creation are too narrow. Pain is not the only experience in which we become attuned to the fact of our having a body; pleasure serves that function, too. (Thomas's account of pain is much more convincing--it is one of the passions, not the paradigmatic fact of human existence.)

And pain is not the only creative prompt. This is, of course, a theological as well as an experiential claim. (Scarry addresses this objection, incidentally, by claiming that apparently gratuitous acts of creativity are only possible in the presence of a cultural abundance itself produced by pain, a claim which has merit but is not sufficient to explain the phenomenon of creativity.) If we are the children of a God who creates out of peace, out of completeness, without external compulsion, then our creativity likewise may not always require the goad of suffering. (I am obviously borrowing from David Hart's book here.)

I must also find fault with her reading of the Old Testament as compared to the New--like all post-Christian liberals, she depends on a trite and anti-Judaic reading of both texts. The "Christianity is an evolutionary improvement on Judaism" motif is too tiresome for words, and the variation played here is neither subtle nor plausible. The Old Testament god functions in the role of torturer; the violence and cruelty of religion is mitigated by the embodiment of god narrated in the stories of Jesus of Nazareth. If god has a body, the concept of god is destabilized in humanity-affirming ways. We make room for peace and democracy and (a Marxist version of) the American way.

I have other, more minor, quibbles with Scarry's work, but these will suffice. In truth, however, none of these quibbles can undermine my respect for what she has accomplished in her first two chapters. Would that I could make these two chapters required reading for participation in civic life!

Science Reporting

I've been interested by a slight change that's been happening recently in science and medicine reporting. I've only noticed it in online AP articles, but perhaps those of you who watch TV or read other news sources can tell me how widespread the phenomenon is.

An example is this article. Like most science reporting I've seen, it mentions the results of the study, where the study was published, and a one-sentence "take-away" message from an "expert" in the field.

Unlike most science reporting I've seen, it mentions the methodology of the study and its source of funding.

I think this is an important step nearer to the sort of transparency that should characterize the communication of science to non-specialists. I have noticed several popular health trends for which the warrant was a single, poorly-designed study (or rather, ones for which the study was not designed in a manner which suggested an appropriate or effective course of action), inadequately or inaccurately reported by popular news sources.

Having the methodology and the potential for bias spelled out so clearly as in this article is a real service to the health consumer, as well as the merely-interested-in-medical-science non-scientist.

I've also noticed that the AP is being more transparent about the relationship between their "expert" sources and those who might have an interest in how a study is reported. Such an example does not appear in the article I linked above, but I've noticed many "expert opinions" tagged with such phrases as "suggests so-and-so, who was not involved in the study" or "commented so-and-so, who had not yet read the report in its entirety."

Again, this seems like a promising and appropriate move toward more transparency. Good thing, that.

Professional Ethics?

I am watching this judicial showdown with great interest.

First of all, by one reading, I, too, belong to a professional organization (i.e., The United Methodist Church) that has its own professional licensing procedures (The Board of Ordained Ministry). Although my organization's professional licensing procedures are not in any sense overseen, supervised by, or practiced at the mandate of any federal or state legislation, there is at least one major circumstance in which my authorization as a pastor is linked to my authorization to provide a legal service: that is, marriage.

What if my professional organization's licensing procedures were in conflict with the state's guidelines concerning the practice of performing marriages? This could potentially come up, given that my professional organization currently forbids its members to officiate at weddings that are considered legal in some states. I am not aware of any cases where my professional organization has exercised its authority in this matter (the UMC is not exactly known for its episcopal backbone), but what if it did? Would the state recognize the right of a professional organization to set its own ethics, even to the inconvenience of the state or its citizens?

This problem is much more acute in the case of medical practitioners whose ethics conflict with the state's interest in carrying out its business. And the scalpel cuts both ways, politically speaking: at present, doctors are permitted to refuse to perform or refer for procedures or treatments to which they have a moral objection, even where state law has recognized access to those procedures and treatments as a civil right. Generally speaking, those who would be in support of the Medical Board's attempt to do an end run around the law with regard to the death penalty tend to be highly critical of practitioners' attempts to do an end run around the law with regard to abortion and certain forms of birth control.

I'm very, very curious to see how it will play out.

Christian Bioethics?

This past week, I began a four-week lecture series in a local church's Sunday School class. The parish, a significant portion of which is comprised of doctors and lawyers, had requested a class in Christian bioethics.

Believing they were expecting a four-week class in "which side to come down on" ethics, and hoping to problematize their approach somewhat, I decided to focus on biblical portrayals of health and sickness for the first three weeks of the class. We won't get to "Issues in contemporary medicine" until the last week.

The first class focused on Old Testament depictions of health. I depended heavily on observations by Norman Wirzba and Ellen Davis on the holistic nature of the Hebrew concept of Shalom--a concept that included human health, of course, but also the health of the land, of the people's relationship to its God, of the politics of the people, and of interpersonal relationships among the people. Not just health, but justice, mercy, forgiveness, love, economic responsibility, and environmental stewardship are encompassed in the biblical concept of health and wholeness.

We looked at texts like Isaiah 65 and Leviticus 26 to ground our understanding of God's desire for all of creation to share in God's Shalom. I'm hoping that they begin to see that "health," as we moderns understand it (i.e., the absence of pathology in an individual body), is a paltry substitute for Shalom.

Better to live on the corner of the roof . . .

Marital Strife Makes You Sick.

Duh.

Conflicting Goods?

I've often been suspicious of the starring role played by the principle of autonomy in most medical ethics treatises.

So it's interesting--to say the least--to hear a presidential candidate propose a solution to our country's health care dilemmas that proposes limiting patient autonomy in a substantial way--or at least penalizing the irresponsible exercise thereof.

John Edwards (Does anybody else keep accidentally calling him Jonathan Edwards?) recently proposed health care policy that would mandate certain preventative measures, including annual checkups and mammogram screens.

Now, this is a very interesting proposal. In many ways, it naturally follows from the combination of the logic of the market and the logic of liberalism, both of which also depend on autonomy as their chief good. Medicine has been almost completely subsumed into both--it has become an enterprise almost completely dominated by its economic side, and government intervention into and regulation of the practice of medicine is taken as normative. (Ask even the most ardent libertarian whether he'd like his son to be operated on by a doctor who was not board-certified.)

So, assuming medicine to be a predominantly economic enterprise, and assuming government responsibility to make this economic enterprise run well, it makes sense for the government to exercise its authority by incentivising and disincentivising behaviors that have economic consequences within the system.

This means you have three disciplines or systems which derive their internal logic from a primary commitment to autonomy, combining in such a way that virtually demands a limitation of individual autonomy. Fascinating.

In all honesty, though, as much as I loathe Edwards' proposal, I think he is the first candidate whose proposals show that he understands the complexities of the health care problem. Few of the other proposals I've seen seem to take seriously the complex interplay of economics, psychology, law, and biology that comprises health care. I'm not sure he adequately addresses the dynamics of the patent system or litigiousness, but he has covered more bases than most people.

The only bit of utter cluelessness came when he said, in response to the question of whether people would find this too invasive, "We mandate public education—public or private—and no one minds that."

Now, I know he's only homeschooling his kids this year so that they can spend time together as a family while he's campaigning. So he's not a hard-core homeschooler. But still, you'd think he'd have heard of a movement of a couple million people who decidedly "mind that." Or maybe have read of the violent resistance that attended the introduction of compulsory schooling?

Books in Review

Hector Avalos, in Health Care and the Rise of Christianity, makes the case that a study of the health care milieu in which Christianity arose is necessary for understanding the attraction that Christianity might have had for, particularly, the chronically ill in the Greco-Roman world.

Avalos helpfully surveys Jewish and pagan sources for indications of the values and practices surrounding sick members of those societies, particularly with respect to chronic illness. The survey of pagan culture is particularly helpful (at least for this non-Classicist) in that it enumerates the different health care options available to inhabitants of the Roman world, as well as the likely cross-pollination between Jewish monotheism and Roman paganism.

I am not conversant enough with Classical sources to know whether his presentation of health and sickness in the Roman world is accurate, but I was disappointed with his survey of Judaism. He dealt almost exclusively with the canonical texts, and seemed to weigh the New Testament critiques of Pharisaism rather more heavily than may be warranted. He did not seem to make use of more modern (and more charitable) studies of Jewish culture in the Second Temple period.

Additionally, his reading of the canonical texts was deeply problematic. He seems to have found in the texts a deep concern for protecting the state (meaning, especially, the levitical priestly hierarchy) from the burden of the chronically ill and underproductive. He takes the strict regulations concerning purity and contamination to be less interested in regulating the spread of contagious illnesses than in isolating and stigmatizing those with chronic illnesses which left them unable to be economically productive. His evidence for this interest is scant--he makes the point that the gradated requirements for thanksgiving offerings after healing (as in Leviticus 14) acknowledge the possibility that chronic illness may render a person economically unproductive, but he implies that levitical regulations are intended to marginalize those persons who have become poor.

He seems to have missed the deep concern for the poor and economically unproductive evident throughout, especially, the priestly code. The passage in question, for example, could be read as a particular effort to include those who have become poor through chronic illness and to mitigate the effects of their disadvantaged position. Economic disadvantage and unproductivity, in other words, is not an impediment to participation in the liturgical life of the community. Chronic illness is, to be sure, but there is little to no evidence that the Jewish community isolated and stigmatized the economically unproductive on a regular basis. Contagion and purity concerns are a much more convincing read of the levitical regulations regarding blood and bodily fluids.

That said, his more basic point is quite sound: whether or not such was the intention of the levitical code, and whether or not the Second Temple Jewish community practiced the levitical code exactly as written, the effect of the canonical regulations concerning chronic illnesses was to create a sub-group of people who would be particularly interested in the healing ministries of Christian missionaries, as well as the theological commitment to non-isolation of "sinners" and lepers.

Both Judaism and paganism, by Avalos's read, created a demographic group of disaffected members of society that would be attracted to Christianity precisely because it rejected (at least in its canonical texts) the very practices that had isolated them from their own societies. This partly explains, Avalos contends, the tremendous growth in the first decades after the death of Christ.

Psychologists Scrap Interrogation Ban

Well, I really like how the APA was thinking here, in the proposed ban. Even though it was ultimately not carried, I liked what they were trying to do.

I'm not sure that they've read their history, though. The Methodist Episcopal church of the nineteenth century passed a ban on ordained pastors owning slaves. The first person to challenge that ban--a Bishop Andrew--was remonstrated and threated with expulsion. All this did was lead to the formation of the Methodist Episcopal Church, South.

I fear that if any such professional organization were to try to enforce such a ban (like the AMA's ban on doctors' participation in executions), we would simply find ourselves with two national professional organizations where once there was one.

Terminal Does Not Equal Disposable

A federal appeals court decided yesterday that terminally ill patients do not have a constitutional right to access highly experimental treatments for their (terminal) conditions, following a longstanding tradition among bioethicists that refuses to see terminally ill patients as disposable.

(Yahoo article here)

While a dissenting judge was appalled at the court's apparent willingness to interfere in what she considered a private choice to pursue life at all costs, I think the writer of the majority opinion and the FDA spokesperson who commented on the decision had the better view of the status, if you will, of terminally ill patients.

The FDA spokesperson was quoted as saying that the decision appropriately balanced the needs for public safety and access to as yet unproven treatments. In her view, then, the terminally ill patient is still a member of the public whose safety the FDA was founded to protect. Like all other patients, the terminally ill patient can be taken advantage of by researchers (whether unscrupulous or merely overoptimistic) and can be harmed by lack of proper scientific knowledge. Their desperate circumstances must not be seen as an excuse to forgo the normal protections and safeguards which are given to the general public (even if the same circumstances lead them to wish to forgo those protections themselves).

The writer of the majority opinion implied the same valuation of the terminally ill patient--their deaths could be hastened by an unapproved treatment, and that premature death would be as much a tragedy as if it were a non-terminal patient.

While the desire to extend every possible opportunity for a terminally ill person to be healed is laudable, it often goes along with a more sinister (and usually unarticulated) re-valuation of the place of the terminally ill person in society. Virtually every time it is proposed that rules, procedures, standards, and policies be different for the terminally ill patient, the difference is intended to mark a separation of the dying patient from the general public, even when the differences are intended to benefit the dying patient. These special policies and procedures proclaim, "The dying person is a different kind of person. The normal rules don't apply."

If this breaking of the "normal rules" meant an increased participation in the life of the community (as in some monastic orders, where the community rushes to the bedside of the dying brother or sister to be with him or her in death, even if it means that the liturgical practices of the community are interrupted), I would be for it.

But it never does, does it?