Universal Access: More Than One Model

I have commented before about the narrowness of the arguments about universal access to health care. What I mean is that most of the time the examples are limited to three. There are arguments about the Canadian model and the British model – usually discussions of their limitations – and about the American model – usually its strengths, although it isn’t really a model of universal access. I have commented before that other nations have other models, and manage to provide universal access to care, almost always at less expense as a percentage of GDP, and almost always with better outcome statistics.

An article in today’s Kansas City Star, my hometown paper, tries to address this. The author, Scott Canon, has looked at a variety of models. He’s also sought comments from a variety of experts on them.

This is a comment article in a paper, and not a scholarly review. On the other hand, it’s the first effort I’ve seen at least trying to show that other nations are using a variety of tools to offer provide universal access. Each model has its strengths and limitations. Each involves some hard political decision-making, and some rationing. On the other hand, our model also involves some hard political decision-making, and involves rationing, however hard we try to deny it.

Take a look at the article. It won’t resolve arguments one way or another. However, it will offer images of more than just three ways of addressing health care needs. That by itself is worth the time and trouble.

On Professionals Praying With Patients

 In an off-topic response to my last post, Frank asked this question:

 

My dad has been in a discussion on another blog about whether a doctor should ask a patient if he could pray for the patient. My mom and dad are very much opposed to a doctor asking a patient if he can pray for the patient. Others think it is fine for the doctor to ask that. Are there any rules at hospitals on this subject?

 

I have two experiences that I think about with this question.  One is the story of a colleague, who spoke of a pre-op visit with a patient.  The patient commented that she hoped her surgeon was a good Christian.  He answered, “At the moment, ma’am, you’d better hope he’s a good technician.”

 

The second is the portion of my orientation of new staff that addresses our System’s policy, “Protection of Religious and Cultural Rights and Beliefs.”  I comment that my goal is that the hospital be a “spiritually safe place;” which is to say a place where each person can be the same person spiritually in the hospital that the person would be elsewhere.  I then note that I’m not the only person who pays attention to spiritual care.  I note that many professionals pray for patients; while a few besides me also pray with patients.

 

Part of that discussion is the need to really think “protection” when we think of a spiritually safe place for patients and/or families.  It might seem trivially true, but it has also been studied.  Patients are anxious, and don’t want to upset the people taking care of them.  That raises the risk that they will say what they think we want to hear.  For the hospital to be a “spiritually safe place,” we really do need to think about protecting that space.

 

That said, I find in my own work that many folks can accept as an expression of good will the thought that someone might pray for them, even if they would not pray themselves or want the other person to pray with them.  Sometimes, too, they will ask for prayer or indicate that they value prayer.  My own thought is that if they ask, and the person asked is both free to accept or decline, and also feels appropriate participating, praying with the patient, or being present while the patient prays, is okay.  Now, if you think that through, that in most circumstances suggests that the patient from his or her position of vulnerability can ask the staff; but the staff person from his or her position of power cannot ask the patient.

 

Now, there is another dynamic in play here.  In the last decade or so health care professionals other than chaplains have been thinking about how the spiritual lives of both patients and professionals affect both relationships and outcomes in health care.  Nurses have actually been including this in their professional discussions for some time.  However, physicians, psychiatrists, social workers, and counselors have also been thinking about the effects of spirituality in their work.  In most instances this isn’t a discussion of faith or miraculous healing.  Rather, it’s recognition that for many individuals spiritual beliefs influence how they live their lives and make decisions.

 

One consequence has been that physicians of faith have felt less pressure to hide.  They have been prepared to acknowledge that prayer is an important part of their lives, and that they pray for their patients, and for help carrying out procedures.  Again, for many patients this is simply a statement of good intention, and they’re not offended.  Some do indeed find it comforting.  So, consider this conversation:

 

Patient: I know things are in God’s hands, and that things will be all right.

 

Physician: Well, I will be praying for that as we go to the OR.

 

Patient: I’m glad to hear that.  Could we pray together?

 

Contrast it with this conversation:

 

Physician:  I just wanted you to know that I pray before all my surgeries.

 

Patient:  That’s good.

 

Physician: May I pray with you?

 

I think the latter conversation verges on manipulation.  Again, if we consider that the patient might well say what we want to hear (and what patient wants to offend his surgeon, however slightly, just before the procedure?), the second conversation is questionable.  But is the first?  The doctor has responded to a comment from the patient with a statement about his own practice, with no expectation of the patient.  If the patient then makes the request and the doctor feels comfortable participating, is this a bad thing?  It arguably strengthens the doctor-patient relationship.  It supports the patient’s hope and lowers stress, both of which have been shown to support health and wholeness.

 

There are some hospitals that have a culture that discourages professionals other than chaplains or clergy from praying with patients.  Those institutions feel that’s necessary to respect and protect the spiritual beliefs of the patient.  They may or may not have an explicit policy; but corporate culture can be very clear and very powerful.  In some environments chaplains feel they have to be the clearest enforcers of such policies.  They distrust the judgments of the other professionals around them, fearing that they will jump too quickly to suggest their own spiritual perspectives instead of respecting the patients’, mostly because they simply imagine that everyone will agree with them, or at least understand them.

 

In my own setting, I don’t have that fear.  New staff members do get orientation from me on the subject, including explicit directions against evangelizing or proselytizing.  They also get diversity training as part of their orientation; and I connect to this by noting that our religious and cultural beliefs are simply another category of diversity that the System expects us as employees to respect. 

 

Now, doctors don’t have that orientation.  At the same time, they are offered opportunities for diversity training, and hear regularly that respect for diversity is a central tenet of the System.  My sense is, both in my own institution and in others, physicians praying with patients are uncommon (although I can well imagine that many are praying for patients).  For those who do, if they do that in a context that’s not manipulative and that satisfies the patient, I’m comfortable.  If I were to learn that is was manipulative, that would be another thing altogether – one that I’d probably find myself in the middle of, at least in my institution.

 

Like so many things that happen in health care, prayer with a patient is one that can be done appropriately or inappropriately.  More doctors feel free to be authentic about their own faiths, and I think that’s a good thing.  If they can be authentic about their own faiths, and also respect the faiths of their patients, that’s even better.

General Convention 2009: Pet Grief

I continue to look through legislation submitted to General Convention, looking for resolutions on health care or otherwise of interest to chaplains. After all, new resolutions are being submitted every day.

While I haven’t found any new resolutions on health care, I have found some of interest to chaplains. One of those is Resolution C078, submitted by the Diocese of Montana. It is titled, “Liturgy for Loss of Companion Animal,” and reads as follows:

Resolved, the House of _______ concurring, That this 76th General Convention reaffirm that all animals are a part of All Creation, for which we are called to be stewards of God's gifts; and be it further

Resolved, That the Episcopal Church embrace the opportunity for pastoral care for people who grieve the loss of a companion animal; and be it further

Resolved, That this General Convention direct the Standing Commission on Liturgy and Music to develop a rite to observe the loss of a companion animal for inclusion in the next edition of the Book of Occasional Services and that it report its work to the 77th General Convention.

This resolution speaks distinctly to an important change that has taken place in our society. When most Americans were rural and agricultural, the animals around them tended to be either tools or hazards. There were the animals kept to produce meat or fiber. There were animals kept as tools, whether as beasts of burden or herding animals or controllers of vermin. There were animals that were simply hazards, whether to health or to crops. There were some animals that might be either hazards or food sources, depending on how they interacted with human agriculture.

Note, though, that none of these were pets. People might become quite fond of them – note how upset we all became about Old Yeller – but they were rarely confused about how they were to be treated and used. No matter how well tended or loved the bull calf, everyone knew from the beginning that eventually he would be slaughtered or sold. No matter how well loved the dog, she lived in the kennel at the back and not in the bedroom.

While that understanding of how humans and animals relate isn’t gone completely, it’s no longer the most common experience. Most of us have companion animals – pets – and not livestock. There are also service animals that share the lives of many. However, the relationships between service animals and those they serve reflect more often the intimacy of pets than the utility of livestock. For most of us, the animals in our homes are not tools but members of the family. We attribute a certain level of personhood to them. For many they are intimate companions, listeners who don’t interrupt, and providers of unlimited affection. For some they become like children, but children who never grow up and leave, who never move beyond their need of us.

With that in mind, I think it important to take seriously grief at the death of a companion animal. I know from both personal and professional experience that the sense of loss is real and significant in the lives of those who lose the animal. This is often heightened by a greater sense of responsibility; for, all too often, we discern suffering in our companion animals as best we can, and choose to end suffering with euthanasia. We have, as I said, attributed some personhood to these animals. We have taken responsibility for their lives, and frequently for their deaths. The grief that we experience in these relationships and these decisions is meaningful in our lives. We have to go through the same grief processes in these losses that we do in any other.

It is also true that often those around us are not as able to empathize for the loss of a companion animal as they are for the loss of a human companion or family member. It is also common that those grieving loss of a companion animal expect less empathy, and so make it so by being less ready to reach out for support. In either case, there may be a particular experience of isolation in grieving a pet or service animal.

These are all reasons for Episcopalians, both clergy and lay, to take seriously grief at the loss of a companion animal, and to offer compassion and support, as well as to seek support when we grieve ourselves. That said, we can consider as a separable question whether the Church ought to establish an official rite for this circumstance for inclusion in the Book of Occasional Services. The authors of the resolution offer this explanation for the resolution:

Various groups within the Church have shown an interest in developing inclusive liturgies for events that touch people's lives, for which there currently exists no authorized rite. The bond between humans and their animal companions can be strong, causing a deep sense of loss, grief (or even guilt) over the animal's death, especially when dealing with the loss alone, without the presence of their community of faith, or having the preconception that such an event falls outside the interest of their church. Our animal companions provide a unique connection to creation and expand our sense of God's diverse gifts in creation. In many cases they also join us as partners in ministry, in such capacities as assistance animals, i.e., seeing eye dogs, etc. as well as therapy dogs and cats used in health care facilities and for pastoral care. An authorized rite in the Book of Occasional Services would give clergy and others a resource for offering pastoral care at the death of a companion animal.

I would certainly agree with the assertions in this explanation. That said, I don’t know whether we really need an authorized rite for “a resource for offering pastoral care at the death of a companion animal.” First and foremost, as a chaplain I’m conscious that the most important act in pastoral care is quiet, sensitive listening. I am certainly prepared to offer a rite; but it’s not the first step. Moreover, while we understand clearly in our worship tradition that some services require clergy leadership while others decidedly do not, formation of a single “approved” rite would tend to narrow our response and to focus on what liturgical leaders do, instead of what we can all do. Parents have been formulating rites for years for the death of a pet. As we appreciate that the reality of grief at the loss of a companion animal isn’t only the experience of children, we can appreciate the capacity of adults to formulate appropriate prayers to honor the losses in their own situations. As an aside, I am not aware of discussion at this point of a revision of the Book of Occasional Services. Such a rite might be seen more quickly if proposed for trial use as a part of the literature of Enriching Our Worship.

I was a visitor to General Convention in New Orleans in 1982, and was present in the House of Deputies as the Hymnal 1982 was debated and tweaked. When a deputy moved to amend to add “He’s God the Whole World In His Hands” to the Hymnal, a member of the Commission noted that it had been considered and rejected. What was important was the reason it was rejected. That was because that much beloved hymn for children is at its best when those participating were customizing it, adding verses in the moment appropriate to the folks participating. He noted then that for our hymnody we were not restricted to the Hymnal, or to other music specifically approved by the General Convention. I would suggest we are in a similar case here. Burial of the Dead is not a sacramental rite, and we already read the rubrics for that rite with some significant latitude. We have latitude as well to create prayers for situations not addressed in the Prayer Book. I think we can use that latitude creatively to mourn the death of a companion animal, whether alone or in a congregation.

I would be interested to see how this gets through the committee process. I think the occasion for this resolution is real. I don’t know that this makes a specific, approved rite necessary.

General Convention 2009: Mental Health (Health Issues 7)

In my last post on General Convention and health, I highlighted resolution C071, titled “Health Care Coverage for All,” submitted by the Diocese of East Tennessee. I also noted that there was a second resolution on health from East Tennessee. That resolution is C073, titled, “Re-evaluation of Care for Mentally Ill.” The resolution itself is brief enough to include in full.

Resolved, the House of _______ concurring, That the 76th General Convention recognize the urgent need to find a way to effect a re-evaluation by the appropriate federal, state and local agencies of the care and long-term treatment of the chronically mentally ill members of our communities; and be it further

Resolved, That this resolution be the beginning of a mission for our country led by the Episcopal Church to develop an action plan with the help of mental health professionals, government officials and church leaders, and other appropriate partners to find ways for communities to move forward with concrete steps to deal with these issues without moving backward into the abuses of the past.

In the explanation, the writers of the resolution made reference to the Community Mental Health Center Construction Act of October 31, 1963. The point of the act was to reduce the number of psychiatric patients were kept, and often simply warehoused, in state psychiatric institutions, and to make treatment available to those patients in their own communities. The thought was that this offered several benefits. It would make it possible for patients to have access to family support. With psychiatric care centralized in state hospitals, often far from family, this could be difficult (and still can be; in Kansas there are two state hospitals still open, both in the easternmost quarter of the state. For families living in the western half of the state, it can be a long drive.). Second, it was thought that with new medications many patients could function in society, well enough to live at home, and sometimes well enough to live alone and be gainfully employed.

I grew up in East Tennessee, and I well remember the state hospital in Knoxville, then known as Eastern State Psychiatric Hospital, or more often just Eastern State. I also well remember when some effort was made to implement the principles of the Community Mental Health Center Construction Act. In Tennessee that took place in the early 1970’s. The governor at the time, Winfield Dunn, was a dentist; and he appointed a psychiatrist to be his Director of Mental Health Services. There was great enthusiasm at the time.

Unfortunately, as the writers of the resolution note in the Explanation, “The mental health care centers that were developed lacked the resources necessary to accomplish their task, thus creating in these past 46 years a large group of people living in degrading homelessness where those with emotional and mental problems have few resources and services, very little follow-up care and no long-term care.” As I recall, state legislators found it exciting to save money by reducing expenses at the state hospitals. They just didn’t find it sufficiently exciting to spend that money in developing community mental health resources. Oh, the centers were built and programs were established; but never with enough staff and never with enough money. The results were in fact two-fold. On the one hand, there weren’t enough community mental health resources to really support those who could live in the community. On the other, there were no longer sufficient resources for those whose friends, families, and caregivers learned really couldn’t live in the community, because the programs of the state hospitals were so curtailed. That was the squeeze that resulted in the “degrading homelessness” the writers identify.

While there have been other issues, that homelessness has been a problem of particular note. It has resulted, I believe, not only in the significant percentage of the chronically homeless who have psychiatric needs, but also in the number of people incarcerated who need psychiatric care. And, notwithstanding the frequent comment that the largest providers of mental health services are now correctional institutions, it’s care that they don’t always receive.

This is a subject General Convention has addressed in the past. Resolution 1985-D127, “Support Ministry to the Homeless Who Are Mentally Ill,” directed

That the 68th General Convention instruct appropriate Executive Council staff to develop and make available to the Church educational resources regarding the plight of homeless people, including those who are mentally ill; to establish, in cooperation with dioceses, Jubilee Centers, local parishes, the social agencies of this Church, other social agencies and the mental health care delivery system, a means of providing assistance for these individuals who are without an adequate support system to meet their needs for care and supervision; and to develop a program of advocacy with other existing organizations on behalf of such homeless people.

Resolution 1991-D088, “Encourage Understanding of Mental Illness and Respond to the Needs of the Mentally Ill,” called for Episcopalians “to become knowledgeable about mental illness…, to reach out, welcome, include and support persons with a mental illness…, to equip the clergy and laity for ministry to the mentally ill and their families and that clergy and lay ministers seek out training and opportunities to minister to the spiritual needs of those who are affected by a mental illness…” among other steps. This was reaffirmed in resolution 2000-C032, “Urge Congregations to Commend and Support Mental Health Support Groups,” with the added suggestion that congregations offer facilities to such support groups. In addition, the important resolutions of past General Conventions on universal access to health care have consistently called for equal and adequate care for mental health as for physical health.

Adequate mental health care continues to be an important issue for our society, with many ramifications. If we can make progress toward universal access to health care, and especially toward parity between care for physical and mental health, we can hope for meaningful changes. This resolution would reaffirm the Episcopal Church’s support for adequate mental health care for all, and especially for those who are homeless or living in inadequate circumstances. Sounds worthy to me.

Published at PlainViews

I have a new piece that has appeared in PlainViews, the online journal for chaplains. The subject will be familiar to my regular readers: being a research-informed chaplain. You can read it here.

If you're a chaplain who stops here and you haven't yet looked at PlainViews, I encourage you to spend some time reading there. PlainViews had information and opinions from and for chaplains on a wide variety of topics. You can read the current edition, certainly; but also scroll down to the bottom of the page and check out the Archives. There are many things there worth reading, and most will take only a few minutes.

If you're looking here having linked from PlainViews, welcome. If you'll look to the left column under "Labels," you'll see categories I've used to sort my posts. That can help you sort through and focus on topics you're interested in. Stay a while, read some, and leave me a comment.

General Convention 2009: Health Issues 6

I have written a number of posts about resolutions  to General Convention that related to health care, or that might be of interest to chaplains.   To this point, those resolutions  have been “A” resolutions coming from one of the Commissions, Committees, Agencies, and Boards (CCAB’s) of the Church.  However, I have continued to review resolutions as they are posted on the General Convention’s web site to note any others that would be relevant.

 

To date I have discovered two, both “C” resolutions submitted by the Diocese of East Tennessee.  The first is C071, titled “Health Care Coverage for All.”  As I have noted, the Report of the Standing Commission on Health did echo the consistent statements of the General Convention in support of universal access to health care.  However, the Report did not include a resolution on the topic.  Thus, Resolution C071 speaks again to that concern.  It reads as follows:

 

Resolved, the House of _______ concurring, That the 76th General Convention call on its congregations to undertake discussions within the parish of the issue of health care coverage in the United States, including:

a) recognition that health is multi-dimensional, with spiritual, social, environmental, and mental elements as well as physical,

b) reminder of personal responsibility for healthy life choices and concern for maintaining one's own health,

c) proclaiming the Gospel message of concern for others which extends to concern for their physical health as well as spiritual well-being,

d) responsibility as a parish to attend to the needs (including health-related needs) of others, both other members of the parish family and those of the wider community, the nation, and the world,

e) recognition that there are limits to what the healthcare system can and should provide and thus that some uncomfortable and difficult choices may have to be made if we are to limit healthcare costs; and be it further

Resolved, That, following up on the discussions within the parishes, communicants, individually and congregationally, be urged to contact elected federal and state officials encouraging them to:

a) create, with the assistance of experts in related fields, a comprehensive definition of "basic healthcare" to which our nation's citizens have a right,

b) establish a system to provide basic healthcare to all,

c) create an oversight mechanism, separate from the immediate political arena, to audit the delivery of that "basic healthcare,"

d) educate our citizens in the need for limitations on what each person can be expected to receive in the way of medical care under a universal coverage program in order to make the program sustainable financially,

e) educate our citizens in the role of personal responsibility in promoting good health with provisions of restricting to some degree treatments for disease in which the patient fails or refuses to comply with good medical practice; and be it further,

Resolved, That this resolution be distributed to all dioceses of the Episcopal Church of America for their consideration and support; and be it further

Resolved, That the 76th General Convention call upon the Episcopal Church to establish and fund a task force to develop action plans and educational materials for dioceses and parishes to conduct the above-described activities; and be it further

Resolved, That the General Convention request the Joint Standing Committee on Program, Budget and Finance to consider a budget allocation of $5,000 for the implementation of this resolution.

Past General Convention resolutions have addressed standards for universal access, including some understanding of what "quality health care" might mean, and approaches to political leaders.  This resolution has some distinctive features.  First, it focuses first on educating and involving members of the Church.   Involving individuals in discussing these issues and contacting their political issues encourages ownership and accountability.

 

Second, this resolution calls for a specific action in establishing a task force to develop materials.  With funding expected to be tight in the next Triennium, I don't know whether actual dollars will be approved.

 

Finally, this resolution addresses specifically and explicitly rationing of health care.  While it doesn't use the term, it does speak of the necessity of limiting and restricting treatments.  It speaks especially of educating both church and community members that some limitations will be necessary and expected if we are to accomplish universal access to health care.  For many this has been a challenge, but the recognition that some personal responsibility and some limits will be necessary.

 

With its call for a task force and funding, and its acknowledgement of rationing, I will be interested to see how this resolution progresses.  It is, however, consistent with the past resolutions of General Convention in calling for universal access to health care.  It is timely, inasmuch as universal access to health care, or at least to health insurance, is a central goal of the Obama Administration.  How much impact this specific resolution has won’t be known for a while.  At the same time, it doesn’t hurt for General Convention to say it once again. 

At Daily Episcopalian: More Thoughts on General Convention

My latest piece is up at the Episcopal Cafe on the Daily Episcopalian page. It's also about General Convention, in the context of my "Second Sermon."

While you're looking at my piece, take a look at the work of my colleagues there, and feel free to leave a comment (I know it's a bit cumbersome, and requires joining TypePad; but TypePad is free, and the conversation is important to us). We want to offer some interesting news, commentary, and spiritual reflection from a progressive Episcopal and Anglican perspective. Come and see.