[ JBEM Index / Volume 9 / Number 1 ]
Pharmacy and Medical Interventions: A Christian Perspective
an address presented March 23, 1996 to the Christian Pharmacists Fellowship International, Campbell University, Buies Creek, North Corolina
Be optimistic. In the long term, the fundamentals are with us.
Medical care has been misconstrued as the treatment of diseases by drugs, surgery, and other means. More properly, it is the treatment of persons who may have diseases, using available means. There is a huge difference.
What are some of the optimistic fundamentals? I would like to look at some fundamentals in three areas:
· the individuality of our patients,
· the economics of medicine, and
· the way pharmaceutical science asks and answers questions.
I. THE INDIVIDUALITY OF OUR PATIENTS.
There is a personal aspect to what we do that produces optimism.
a. The persons we serve are image-bearers of God.
‘And God said, let us make man in Our image, according to our likeness; let them have dominion over- the fish of the sea, over the birds of the air, and over the cattle, over all the earth and over every creeping thing that creeps on the earth.’ So God created man in His own image; in the image of God He created him”
(Genesis 126- 27 a).
This image cannot be our physical make-up, since God is a spirit.
“God is Spirit, and those who worship Him must worship in spirit and truth”
(John 424).
The persons we serve have a spirit. That spirit is intimately connected to their bodies and the ailments of those bodies. Only personal contact by nurses, pharmacists, doctors, and others can effectively touch that spirit and its resources. We serve persons and we use bags of chemicals as part of the means. We do not serve bags of chemicals.
b. The persons we serve are individuals. The story of Joseph in the Old Testament is not the story of Joseph of Arimathea in the New Testament. God does not deal with us by simple diagrammable rules. Though He is operating according to His immutable nature, in which we can discern principles, He is doing so by engagement with the rich, intimate details of our personality. Matthew is called from his tax extortion and Zacchaeus from a tree. Peter is called from fishing for fish to fishing for men. Paul, who thought he could see sin clearly, is called in blindness from a murderous trip and sent on missionary trips. There is a sameness in the call, but also wonderful differences in its particular administration.
Those people we serve have their individual stories and circumstances. They have idiosyncrasies. Sometimes their idiosyncrasies are annoying. Yet, no mega-system, no algorithm, no Michaelis-Menton
equation can capture these individual differences. No classification scheme of personality types, temperaments, genetics, or DNA patterns adequately describes the rich individual differences God has determined. Only individual practitioners can take into account the individuality of our patients. Remove us from the system, overly burden us with regulations from some Organizationon-High, or require us to deal with people only as they are described by a few categories, and this vital personal aspect will be lost and the care of the sick will be lost with it.
At this point, as a favorite hobby horse, I’d like to say that out-of-state pharmacies are handicapped. Such pharmacies can deal only with voices on the telephone and slips of paper from the mail or FAX. The alcohol on the breath, the fear in the eyes, the poverty of the dress, the obviously blinded eyes, and so forth, are going to be missed.
About ten years ago some family practice researchers reported on the factors associated with recovery from seven sets of common symptoms. These were such things as abdominal pain, back pain, chest pain, fatigue, headache, and so on.- They measured the technical aspects of the care:
Did the physician take a good history?
Did the physician keep a problem list in the patient’s record
Was the doctor’s examination of the patient appropriate?
Were appropriate drugs prescribed?
Was the follow-up appropriate?
They also checked on the recovery from the symptoms one month later and three months later. The things they rated are the sort of things which physicians are judged on by our overseers to see whether or not we are good physicians. The researchers looked to see which of these technical aspects of care related to recovery.
Zip. Zero. Nothing technical that the physician did related in any important way to recovery, though most of the patients recovered. There was only one thing which related to recovery, as far as physician behavior was concerned: If the patient and the physician agreed as to the nature of the problem, that agreement was related to recovery. Some other things did relate to recovery, such as the amount of stress in the patient’s life, and the duration of the symptoms before the patient came to see the doctor, but those were not features involving physician behavior. Mutual understanding. How simple. How non-algorithmic. I’ve never seen it in any assessment of “good medical practice.”
You explain to some of your customers about the drug you are dispensing. Excellent, clear explanations. Yet some of them you know didn’t “get it.” You can tell it at the time. You can try again or find someone else in the household who can grasp it. For some others, you are wasting your time, because they already know what they need to. Good practice must allow this kind of individualization.
c. The persons we serve are accountable. 1 Corinthians 3:1(-17: “Do you not know that you are the temple of God and that the Spirit of God dwells in you? If anyone defiles the temple of God, God will destroy him. For the temple of God is holy, which temple you are.” Later in 1 Corinthians we are reminded that we are “not [our] own” and that we are “bought at a price.” 1 Corinthians 6:19-20. In the book of the Revelation we are told that there is a judgment of all. A managed care organization may regard its subscribers as a number, an account, or some other kind of cipher, but we know them as persons with faces, who have certain habits (like showing up drunk or two minutes before closing time, or trying to get one child’s medicine on another child’s Medicaid). To the insurer they are simply “a risk” which can be managed by the averaging power of large numbers in a policy-holding group. No one in Insurance Command Central is answerable before God for the health of the insurance policyholders. Those of us who know the patient can remind the patients of their personal responsibility. When the occasion permits, which in these days is, I think, rather rare, we should remind our patients.
It is unhealthy to be irresponsible. Health is not a commodity which can be purchased from “providers.” Insofar as we have control over health, it flows from our beliefs and our behaviors.
We have “health food” stores frequented by people who are sometimes very particular what goes into their mouths. Yet, some of the same people take little heed what they feed their minds. “For as he thinks in his heart, so is he” (Proverbs 23:7 a). This verse occurs in a context of what happens when someone is eating. Have we not turned our priorities upside down? For example, how do people today think and behave with respect to raising their children? A promise of health is attached to the Fifth Commandment. The New Testament calls it the “first commandment with promise.”
“Children, obey your parents in the Lord, for this is right. Honor your father and mother,’ which is the first commandment with promise: `that it may be well with you and you may live long on the earth “‘ (Ephesians 6:1-3 ). The father, not a school-be it public or private–is ultimately the one responsible for how his children are trained. It matters for health, among other things, how those children are taught. Deuteronomy 6: 2-3, and 6-7 says: “that you may fear the Lord your God, to keep all His statutes and His commandments which I command you, you and your son and your grandson, all the days of your life, and that your daps may be prolonged. Therefore hear, O Israel, and be careful to observe it, that it may be well with you, and that you may multiply greatly as the Lord God of your fathers has promised you…” “And these words which I command you today shall be in your heart; you shall teach them diligently to your children, and shall talk of them when you sit in your house, when you walk by the way, when you lie down, and when you rise up.” If we love God, we are to keep His commandments. “If you love Me, keep My commandments. ” said Jesus, as recorded in John 14:1 “Those who forget not God’s law…will have length of days, and long life, and peace.“
Proverbs 3:1-7 says, `My son, do not forget my law, but let your heart keep my commands; for length of days and long life and peace they will add to you. Let not mercy and truth forsake you; bind them around your neck., write them on the tablet of your heart, and so find favor and high esteem in the sight of God and man. Trust in the Lord with all your heart, and lean not on your own understanding; In all your ways acknowledge Him and He shall direct your paths. Do not be wise in your own eves; Fear the Lord and depart from evil. It will be health to your flesh, and strength to your bones.”
Does a child despise authority? When the school calls and reports significant misbehavior, is the parent set to see to it that the child respects the school’s [delegated] authority? Or, is the parent irate that his little angel has been sorely tempted by careless teachers and is guiltless of misbehavior? Among other things, this kind of situation is a health issue, even though it doesn’t look like one. Pharmacists and nurses and doctors are not involved.
A father tells his four year old to go into the house. The four year old hesitates, then trundles off in another direction. The father does nothing. Mistake not. Learning has just taken place, and the learning is contrary to good health. Multiplied episodes of that sort have far more to do with the ultimate health of that child than eating meals laden with cholesterol or devoid of fiber.
The Fifth Commandment contains within it accountability to all legitimate authorities established by God. As the fifth, it stands as a hinge between the first table of the law, the first four commandments, which summarize our accountability to God, and the second table, the last five commandments, which summarize our accountability to men. Failure to heed legitimate authority is deadly.
We in the healing professions, therefore, need to support, not undermine, legitimate authority, We should not usurp to ourselves authority which God has lodged elsewhere. I’ve used an example of children. For adults, our health is not something that can be passed on to a cadre of health priests who, for a fee, will keep us healthy no matter what we think or how we live. Holding the people we serve reasonably accountable for their own participation in their medical care is one way to do this. There is a physician in the West who has patients keep their own medical records! Think of the benefits. No worry about confidentiality. The patient has control. Reduced costs to the patient, since there is no need to employ medical records personnel. No mystique. The patient can read them. Participation. The patient has a section to write in them. So can nurses and pharmacists and therapists of various sorts.
I hear the objections: They may alter the record and sue you. They are careless and lose them. The dog may eat them, if he is not too full from the children’s homework. As to the first objection, there is a presumption in law that the person who has control of the records may indeed alter them. The practitioner is actually freer to assert what he/she actually did than if the records are in our control. Of course, patients will lose records. Who doesn’t? If the patients’ carelessness is a reason not to tender to their custody a sheaf of paper, how is it then that we hand to them potentially lethal chemicals by the bottle full? Isn’t there a contradiction in our reasoning?
I appreciate the way pharmacies do drug labels today. The refills, right across the bottom. Who is accountable not to let a chronic medicine lapse? Not me. Not you. You’ve told them. Will we help them if they run out? Of course. But, if a patient begins to “crawl my case” because I didn’t call the pharmacy instantly to refill his thiazide, or whatever, I remind him that I cannot and will not promise to be instantly available for anything, especially not foreseeable events. I am Dr. Teflon. It is not just self-protective. It is health promotion. If I routinely do for them what they can and should do for themselves, I am acting against their health. 11 Thessalonians 3:10 says: `For even when we were with you, we commanded you this: If anyone will not work, neither shall he eat. ” Requiring patients to be responsible for such things turns off a few of them, but I probably cannot help them anyway. That clan wants to have me as their paid private priest, rescuing them perpetually from the medical consequences of their own lapses. That is not a workable model for medicine. It is not a Biblical model. As a doctor I am accountable to patients as their adviser and assistant. I am not your mother. I am not your father. I have no authority over a patient. I want none, though the “managed care” organizations including Medicaid and Medicare want me to control the patients like so many cattle.
You want to send your prescriptions off to an out-of-state pharmacy? I advise you, you are going to miss out on a service, not the least of which is the availability of a local pharmacy. You are going to forget to send for refills in time for them to arrive. You are going to move and they are going to send your Corticodigomycin to your old address. When that happens, understand that neither am I going to promise to be instantly available to make the drug locally available for you. I prefer the local pharmacy.
II. THERE IS AN ECONOMIC ASPECT TO WHAT WE DO THAT PRODUCES OPTIMISM.
Like everything else, economic realities are realities provided by God. Christians too often toss off money as “mere money,” as if Godliness is in some way never concerned with money. Not so. In fact, our wilfull ignorance of God’s provisions in economics has led us to the misconception that basic medical care, including the pharmaceutical provisions of it, can be managed by insurance. Not. Cannot be. Laws and regulators and insurance companies cannot make it so any more than they can revoke the law of gravity. Medical insurance is not an answer to the problem of medical costs. It is one of the principal reasons for the high costs. We need not more insurance, covering more people for more things; we need far less insurance, covering far fewer things, and for fewer people. Biblically consistent provisions in insurance were stated well centuries ago. See how they conform to a Biblical understanding of fallen human nature.
a. Basic medical care is an uninsurable risk
To be an insurable risk a risk must be:
Unable to be faked . Can you fake a bellyache? The very word “hypochondriac” derives from the fake bellyache. Fallen humans bear false witness sometimes.
Substantially outside of the control of the insured . Is my heart attack unrelated to decisions that I make? They insure a farmer’s crops against hail, but not against weeds The former he cannot control. The latter he can. With basic medical insurance, we encourage people to allow health weeds to grow up in their lives, then use the insurance to remove them. Fallen human beings can be poor stewards of things God has put under our control. Therefore, we need systems that encourage good stewardship, not ones that reward poor stewardship.
Significant in size, not economically trivial . Does anyone sell dry cleaning insurance? Big surgical bills might be insurable, but not visits for ankle sprains or sore throats. Again, the principle here is stewardship. A surgeon’s bill for $3000 for brain surgery may incur $50 in costs to handle the billing. That is about 1.5%. The physician’s bill for an office visit for otitis media may be $45. The billing costs will be about the same, making the billing cost 110% of the cost of the service. That is the system we have in place now in some insurance plans.
Objective , not covert. How objective is a backache? Human beings cannot see into the spirit of another and therefore cannot make and enforce contracts which pretend that we can do so.
Unlikely to occur to many in the insured group . What proportion of the population does not become ill? The Bible assures us that trouble comes to us as surely as sparks fly upward, and that it is appointed unto man once to die. Insurance makes sense for unlikely losses with a high cost, such as your house burning down. For nearly certain expenses, it amounts only to a redistribution over time of the expenses you are likely to occur, overseen by third parties at a charge by them of about 20%.
Basic medical care fails to satisfy any of these fundamental requirements. Therefore, all public or private schemes to create an insurance payment system will fail. It is as certain as gravity, which cannot be repealed by law. Neither government nor the insurance industry has the power to overturn human nature. They have to accede to it just the way everyone accedes to gravity or breaks something.
The present craziness in medical and pharmacy payments defies basic fallen human nature. The book of Genesis tells us of humankind’s fall from our sinless state into a state of hatred of and rebellion against God and what He has instituted. The teaching is called “Original Sin,” and we all have it. Anyone who believes in the innate goodness of mankind has failed to observe two and three year olds very closely. The economic, social, political, and medical structures–every institution of mankind-needs to take into account this fallen state. The chief difference between a political liberal and a political conservative is that the liberal believes in the basic goodness of people, and the latter believes in the basic fallenness of people.
(Continued in next issue)
Notes
1. David Asch and John Hershey, in a fascinating article in the Annals of Internal Medicine, discuss “Why Some Health Policies Don’t Make sense at the Bedside., [Ann Intern Med, Vol. 122 June, 1995, pp. 84(r 8501 They point out that “cost-effectiveness,’ as it is ordinarily calculated, aims at defining what is the best practice for a herd and may not at all be best for any particular cow in the herd. [They actually use the herd analogy.] if for example, a veterinarian knew that administration of a particular drug in the feed of a herd of cows would preserve 1% of the herd from dying, but would kill 0.3% of the herd, the choice veterinary practice would be to administer the drug. If most of the animals which were susceptible to dying from the drug could be identified ahead of time, but only at a cost that exceeded the market value of animal the veterinary choice would still be to administer the drug in the feed. In human medicine, however, there are obvious problems with such a decision, since human beings do not have, or should not have, a government-determined “market value.” Interestingly, a committee of the Centers for Disease Control and Prevention recently recommended resurrection of the injectable, killed, polio vaccine because the approximately eight cases of paralytic polio per year in the U.S. that are caused by the live oral vaccine are no longer tolerable. To quote the advisory committee: “We cannot face, as many of us do, eight sets of parents each year whose children are on ventilation support or [wearing] braces because they have received a vaccine for a disease [the parents] have never ever seen.” [from vaccine Policy Digest Vol. 11, which cited the Oct. 19, 1995, New York Times and the journal Infectious Diseases in Children for November, 1995.] Just last month we saw the recommendation, soon to be a law, that certain common foods in the U.S., such as bread, be required to have folate added. Now, I am not aware of any side effects of folate and heartily recommend the vitamin to young women who are, or are likely to become pregnant, in order to reduce the chance of neural tube type birth defects, ranging from anencephaly to spiny bifida. I am reminded, though, of the fluoride in drinking-water controversy, which raged in the 1950s, where the ultraconservative “crazies” were aligned against the liberal “enlightened.” Let us assume that the widelybelieved benefit of fluorine against tooth decay is correct, though I am not really convinced. Other evidence has it that fluorine in drinking-water, even in moderate concentrations, increases the risk of hip fractures later in life, since it weakens cortical bone and strengthens only cancellous bone. [See Jacqmin-Gadda, H., et al., in JAMA March 8, 1995, Vol. 273, pp. 775-776, and bibliography cited there.] When public health policymakers mandate folate in food or fluoride in water or rubella vaccines in infant boys, are they not acting as veterinarians over a herd Did God grant them that authority? If so, where in Scripture is the grant recorded?
2. Bass, Martin J., et al., “The Physician’s Actions and the Outcome of Illness in Family Practice,” Journal of Family Practice, Vol. 23, pp. 43-47, 1986.
[ JBEM Index / Volume 9 / Number 1 ]