Wednesday, October 14, 2015

By Warren Kinghorn, M.D., Th.D.
from DIVINITY Magazine

Marty Smith is back.” The emergency department (ED) nurse’s tone was flat, neither pleased nor surprised.  Indeed, from my seat a few feet away from where mental health patients in crisis were evaluated, I already knew that Mr. Smith was back. A familiar string of slurred curse words had just filled the quiet ED, and a familiar smell of stale alcohol hung in the air. Marty was back for his 40th emergency department visit in about 50 weeks. As an emergency psychiatrist, I had cared for him before and knew how this visit would go. Marty would say, in his drunken state, that he hated alcohol and wanted detoxification. He would be given a meal, perhaps some intravenous fluids and medication, a thorough medical examination, and a place to sleep. In the morning, more sober and less agitated, he would insist that he was feeling better and did not want further treatment, despite the strong encouragement of the staff that he go to a rehabilitation center. He would leave, and would be drunk again by midafternoon—and would stay that way until he next came to the ED.

Over the course of those dozens of visits, I came to know Marty (whose name and other details have been altered to preserve confidentiality). He grew up in a home of millworkers in a nearby county and described a peaceful childhood until he discovered a liquor bottle in the family cupboard when he was 12—and he had not stopped drinking since. Alcohol had cost him a series of jobs, all contact with his family, and any chance of stable housing. He had little hope that he would ever stop drinking, and that despair spread to the nurses and doctors caring for him, who wondered whether such care was wasteful and futile. But then, in a miracle of hope, I watched as a determined, no-nonsense hospital social worker built a trusting relationship with Marty and eventually secured an apartment for him—an apartment which, by contributing to his safety and reinforcing his dignity, allowed him to cut down on his drinking and to stop coming as frequently to the ED. When I occasionally see him now, we greet each other and he is stronger, brighter, more engaged—and never smells of alcohol.

Medicine and Its Moral Commitments
People like Marty Smith never end up on the glossy brochures or television advertisements of American medical schools and hospitals. In a health care system that increasingly stakes its worth in technological innovation, what Marty needed most was not any new technology but rather what all of us need when we are stuck in low places: relationship, time, care, patience, and love. The “treatment” that made the difference for him—stable housing—was not even something a physician could prescribe. Marty is his own person, with his own strengths and ability to contribute to the world around him. During those dozens of visits, however, there was nothing instrumental that he could provide to the health care system that treated him: not money, not insurance reimbursements, not prestige, not political connections, not even the satisfaction of a rare, exotic, or complex “good case.”

Moreover, being with him at those times was often not easy: he would never strike anyone, but he would curse and spit and threaten and defy instructions. And yet I am never more proud to be a clinician within the American health care system than in times like those. For all of their faults—and they are many—modern American hospitals are places where anyone can come to an emergency department, say that they are sick or in crisis, and be cared for, regardless of insurance status or ability to pay. And most nurses, doctors, and other health professionals are still the kind of people for whom being sick—not  sick and wealthy, or sick and polite, or sick and important—is reason enough to treat someone with dignity, compassion, and respect.

These time-honored practices of hospitals treating people who are sick and in crisis regardless of ability to pay, and of clinicians treating people with dignity, compassion, and respect regardless of who they are or what they contribute, are at root moral commitments. These moral commitments are sustained internally in the professional formation of clinicians and are sustained externally by a culture that has expected no less of its health care systems. It is easy for us to take these moral commitments for granted, to assume that health care must run that way, that there is something about being sick that exerts a moral claim on those who are able to provide care. At the least, these commitments don’t seem specifically religious or theological: the clinicians who walked so faithfully with Marty Smith were formed within a wide range of cultural and religious contexts and worked in a nonsectarian health care system.

Unfortunately, these moral commitments are at risk within the political and economic culture of health care. Large-scale opposition to the Patient Protection and Affordable Care Act of 2010, while focused mostly on the role of the federal government in regulating health insurance, highlights the degree to which many Americans resist the economic burden of providing universal access to health care. A 2010 survey by the Association of American Medical Colleges showed that only 22 percent of students entering U.S. medical schools planned to practice in underserved areas, and that those who were undecided at matriculation were more likely than not to decide by graduation against doing so. A recent survey published in JAMA Psychiatry revealed that only 55.3 percent of American psychiatrists accepted private insurance payments in 2009–2010, with even fewer accepting Medicaid. People who are sick and who lack resources may not be turned away from emergency departments, but they are regularly prevented or denied access to many other health care settings and services. This is in part, of course, because American health care expenditures continue to climb higher and higher, particularly payments for new technologies and forms of therapy—with no consensus regarding what is enough.

The Church and the Development of Health Care
In the face of the complex economic and political challenges of modern health care—all of which are, in some way, moral challenges—it may seem simplistic to turn to the church for answers. We frequently hear that American churches’ social and cultural influence is declining, a function of shrinking membership and an ever-increasing percentage of the population that affiliates with no religion at all. The total budgets of American religious institutions are dwarfed by the 17 percent of the U.S. gross domestic product that is spent on health care. And yet, for Christians, metrics of political and economic influence cannot be the final word. It was to a community of far smaller membership and social influence, after all, that the apostle Paul wrote, “Although I am the very least of all the saints, this grace was given to me . . . to make everyone see what is the plan of the mystery hidden for ages in God who created all things; so that through the church the wisdom of God in its rich variety might now be made known to the rulers and authorities in the heavenly places” (Ephesians 3:8–10). How, then, might the church witness to the renewal of health care?

Hospitals that exist to treat people who are sick simply because they need care, or charity hospitals, are so much a part of our culture that it is easy to forget that, like all institutions, they have a particular social history. But pre-Christian Greece and Rome had no charity hospitals. There were, to be sure, healers like the Hippocratic physicians and the great Roman physician Galen, as well as the cult of the healing god Asclepius. Physician clinics existed, along with medical institutions devoted to functional purposes such as the care of slaves (to return them to labor) or soldiers (to return them to battle). The civic virtue of philanthropia, “love of humankind,” inspired wealthy patrons to endow institutions for the benefit of the population, thereby bringing honor to themselves (a tradition well-represented in modern research universities). But no institutions were devoted to caring for those who were sick simply because they were sick, or to providing for those who were homeless and poor simply because they were in need. Medical care took place largely within households, and those who were sick and who lacked money, status, or kin were largely left without support.

The church changed that. Drawing from the example of Jesus and his roots in Jewish ethics, Christians began to care for “the least of these” in society, people who were entirely unnoticed and disregarded by the Greco-Roman elites. Historian Gary Ferngren has highlighted the way that some early Christians distinguished themselves among the Roman population by risking their own health and safety to care for victims of Roman plagues and to establish networks of social support; the fourth-century emperor Julian memorably noted that “the impious Galileans support not only their own poor but ours as well.” This commitment to serve the poor and to care for the sick fueled the growth of Christianity in the third and fourth centuries, and this recognition of the importance of care for the most vulnerable is a Christian legacy that should compel us to assess what kinds of people are valued in modern medicine.
Most notably, Christians backed up their concern for those who were sick by founding hospitals devoted to their care—the first documented charity hospitals. Historian Andrew Crislip has shown that some early Christian monasteries developed infirmaries for the care of sick monastics and medical attendants to care for them, the first recorded description of nurses. In the late fourth century, in what is now eastern Turkey, monasteries influenced by St. Basil of Caesarea began to extend medical care not only to sick monastics but also to people outside of the monastery who were sick, homeless, hungry, leprous, or poor. These nosokomeia (“places for the care of the sick”) or xenodocheia (“homes for the stranger”) were modest institutions, but they are part of the historical lineage that led to the developed hospitals of the Byzantine empire and to modern charity hospitals—including the hospital where I met Marty Smith. The moral commitment that modern clinicians demonstrated to Marty is, in part, related to a strange ancient people who were formed to look at the body of a sick person and to see Jesus; who were not afraid to touch sick and diseased bodies because death had been defeated; and who transformed philanthropy from a generalized “love of humankind” (the stuff of seminary and medical school application essays) to a specific, incarnate love of this person, this fetid breath in which we are met, miraculously, by the Holy Spirit.

The charity hospital is not the church’s only contribution to health care. The first psychiatric hospital in the Western world was founded by a Spanish monk, Juan-Gilaberto Jofré, in 1409. Community mental health treatment traces its roots to the Belgian community of Geel, in which medieval townspeople began housing persons with mental illness who sought healing at a local shrine. And inpatient psychiatric care was profoundly humanized by 18th- and 19th-century Quakers who developed rural communal “retreats” in place of dirty, confining, urban hospitals.

To be sure, the church’s contributions to health care have not always been positive. Christian “charity” can become disempowering and dehumanizing, contributing to the stigmatization of those who are sick. Christian medical missionary work has all too often colluded with European colonialism. And Christianity may even have contributed to the technological excesses of modern biomedicine. Theologian Gerald McKenny has argued that medicine’s commitment to relieve suffering and to postpone death by manipulating the human body was fueled by Francis Bacon, the 17th-century philosopher who combined the Protestant affirmation that creation is given to humans for them to use along with the Protestant commitment to the relief of suffering. Bacon’s project to relieve suffering by manipulating nature continues to drive medicine today—especially when we have lost the ability to narrate what the limits of technology are, what human life is for, and what kinds of suffering ought not to be addressed by technology.

The Church and Health Care Today
In the context of this rich history, both positive and negative, the church must engage contemporary health care. Christian organizations still affect the institutional shape of health care across the world: the Catholic church is the largest nonprofit provider of health care services in the United States, and Christian mission hospitals and mission agencies continue to provide essential medical care in many parts of the developing world. Additionally, Christian churches and congregations are more geographically widespread and localized than any health care system ever will be. They remain the primary places where people find the relationship, care, patience, and love that all of us, including Marty Smith, need at times of crisis. And they remain powerful shapers of imagination and practice with regard to health and health care. What opportunities and responsibilities, then, should the church embrace with respect to modern American health care? The list here could be long, but I close with three broad categories.

First, the church must continue to shape the imagination of health care institutions in ways consistent with Christian faithfulness. This is partly a matter of encouraging theological vision within established institutions that are already church-related, such as Catholic hospital systems. But the days are long past when Christians can presume ownership of major health care systems. Rather, the church should remember that its most significant health care innovations started with local practices of faithfulness, like the modest infirmaries of St. Basil that gave rise to the charity hospital. In local institutions and practices—congregational health ministries, community development partnerships, and smaller faith-based institutions like Lawndale Christian Health Center in Chicago or Siloam Family Health Center in Nashville—the church may yet bless the institutional shape of American health care.

Second, beyond institutions, the church must continue to shape the moral imagination of clinicians. Sadly, this is not always the case: a recent nationwide survey led by Dr. Farr Curlin, Josiah C. Trent Professor of Medical Humanities, demonstrated that U.S. physicians who frequently attended religious services or who considered themselves highly religious were not more likely than others to care for the underserved. Christians must reclaim our earliest identity as a people who, when others would not, cared for plague-ridden bodies, sheltered those without housing, and treated those who were sick. Christian congregations and centers of theological education like Duke Divinity School can lead in encouraging present and future clinicians to reclaim this vision—a vision like that of Thomas Catena M.D.’92, a Duke-trained surgeon at a Catholic mission hospital in Sudan who commented to the Duke Medical Alumni Bulletin that “our faith keeps us going. We’ve been reading the Gospels this week and understand that suffering is part of the journey. This is somewhat our lot in life and we understand that.”

Finally, the church must shape the imagination of patients—that is, all of us—with regard to health care. American health care at its root is driven by market forces. It will deliver what consumers ask for it to deliver, and it will respect the limits that consumers place (or do not place) upon it. Reform cannot be driven only by health care institutions, policymakers, and clinicians; it must also be driven by consumers who know when to say enough to expensive and marginally beneficial technologies at the end of life and at other times, and no to health care systems that leave many vulnerable Americans with no insurance coverage. In a country where over 70 percent of the population still identifies as Christian and where over one third report weekly worship attendance, Christian congregations can and should be places where Christians learn how to engage health care faithfully.  As Stanley Hauerwas, Gilbert T. Rowe Professor Emeritus of Divinity and Law, has said, in order to sustain its commitment to be present day in and day out to those in pain, medicine needs something like a church, “a people who have so learned to embody such a presence in their lives that it has become the marrow of their habits.”

The church can now, as in the past, articulate and advocate for the wisdom of God in contemporary health care. In our commitment to see Jesus’ face in each person who is sick, in the way we care for one another, and above all in our commitment to love God’s good world as God does, the church can bear witness to a more human and faithful health care system—a system that respects in all of us, including Marty Smith, the dignity appropriate to our status as embodied children of a faithful, healing God.