Recognising I can't solve the world

I currently work on an acute medical ward. Our patients are poorly, but mostly in the short term we can diagnose and solve their problems so that they can be followed up as outpatients or by their GPs. Their medical problems, that is. We have limited success with their social problems, and as for their spiritual problems...

My patients are challenging, even when medically they are straight forward. What do I saw to the young woman who has overdosed three times this week but says she isn't trying to kill herself. Can I ethically give her any medication at all to take home, even though she's in pain? Actually I would rather sit down and explain to her that she is loved and has incredible dignity and that even though life has treated her badly, it doesn't have to be this way, but I can't do that because I don't have time and I don't have any kind of relationship with her, she won't even make eye contact.

How do we deal with the patients with serious mental health issues? If I have 3 hours to review 25 patients, I can't really deal with the one agitated patient who wants to ask me a lot of (possibly irrelevant) questions, who is never there when the doctor comes to see her because she keeps going out to smoke, and who is only in hospital because their persistant self-harm makes a not very serious problem much, much worse.

And then there's our favourite frequent flyer who is frankly, bonkers, (psych assessment pending) and also seems to think that every single member of staff on the ward is there only for him. He needs a pen, he needs the phone, he just wants to talk and medically speaking, he doesn't really need to be in hospital. He's also either seriously confused, in denial or compulsive liar. As my technician said to me this morning, his readmission has ruined the whole week.

As a Christian, I know I am supposed to love these people. What I am learning though, is that the best way to love them is to do my job. So I might want to sit down with them, and their families, and their neighbours, and work out how best to look after them (because their non-medical problems are so much worse than their medical problems) and solve everything, but that's not what I'm there for, nor any of my colleagues, and their problems are the problems of the world and will definitely take more than three hours to fix, but I increasingly doubt whether anyone outside the hospital has realised this.

Professor Dawkins and the increase of the sum total of happiness

Poor Professor Dawkins has apparently caused a furore on twitter after tweeting, to a woman who said that she would face a serious ethical dilemma if she found she was pregnant with a baby who had Down's Syndrome, that she should abort it. He seems suprised by this. His apology, as reported by the Guardian, seems to be an apology for causing a riot rather than for what he actually said, claiming that those who objected did so from an emotional point of view, that twitter did not give him enough space to put his whole argument across and that because of this he left himself vulnerable to wilful misinterpretation.

However, the thing that really bugs me about this is that Dawkins claims that his response is totally down to logic. According to the Guardian, he wrote: "If your morality is based, as mine is, on a desire to increase the sum of happiness and reduce suffering, the decision to deliberately give birth to a Down's baby, when you have the choice to abort it early in the pregnancy, might actually be immoral from the point of view of the child's own welfare." I take issue with this, and in fact, I am frequently irritated by people who claim that anyone who disagrees with them is arguing emotionally, and that they themselves are basing their argument purely on logic. 

• If your morality is based, as Professor Dawkins' is, on a desire to increase happiness and reduce suffering you should presumably never say anything that might offend anyone because offense generates suffering, even if this is a subjective response. 
• If you believe that this life is all there is, that there is no life after or other than this one, then the abortion of an unborn child would presumably decrease the sum total of happiness, seeing that without life there cannot be happiness.
• If your aim is to increase the sum total of happiness rather than the happiness of the individual, and given the amount of great joy which those families express regarding their children with Down's Syndrome (and indeed their children without Down's) then presumably the termination of a child would not increase happiness and the reduction in suffering (given the absence of the child and the effects on the family) could well outweigh the non-increase in happiness.
• Given that people who are objectively suffering can experience happiness, and that people who are happy can suffer, suffering and happiness are not necessarily opposed and therefore the aims to decrease the former and increase the latter may, in fact, be conflicting.
• By extension of his argument that it is immoral to maintain life where there is suffering, all those who suffer from any illness, or indeed with the potential to suffer from any illness, however short or long term, should be exterminated because their existence may lead to their own suffering or the suffering of others.

Given the logical outcome of his moral framework, perhaps it is time to reconsider the starting point. If the outcome is outrageous and not what he intends at all, perhaps that is because some of his reasoning is based on an emotional understanding of happiness and suffering. 

Carey and Tutu should really know better

Over the weekend I found myself astonished by the comments of Lord Carey and Archbishop Tutu on assisted dying. 

As the Lords prefer to debate Lord Falconer's proposed assisted dying bill, these two prominent Anglicans have chosen to speak in favour of such a law, and have been widely reported as doing so. Unfortunately few people will read the actual statements which were made, and these certainly deserve further examination.

Carey started the ball rolling with his article in the Daily Mail (his original article is at the end, the first section is a review both of his comments and the Bill). He makes several points:

• Modern medicine is capable of ending life as well as prolonging it.
• The law (and the Church) need to catch up with reality.
• Arguments of the slippery slope type 'lack power and authority'.
• Benevolence and compassion are more important than doctrine: Christian theology needs reinterpreting. 

The ability to cause death is not new (see history). Carey claims that the fact that drugs such as morphine, given to ease pain, may hasten a person's death and argues that given that this may happen, we could and should use them to cause the patient's death. This is merely an extension. In fact 'modern medicine', as lauded by the former Archbishop of Canterbury himself, is capable of controlling doses so carefully that such a 'double-effect' is now negligible. He also fails to recognise that as it is the primary intention which has changed (causing death vs analgesia) this is not a mere extension of an unavoidable effect but a completely different action. First, do no harm. The former 'first' is the alleviation of pain. The latter is to actively seek to end the patient's life. 

Then we have the reflecting reality/moving with the times argument. There is only one thing to say about this: Dictatorship of Relativism. In this country we seem to like this argument. People are having abortions, let's legalise them. People want to marry others of them same sex, go for it. 

As to the lack of authority in the slippery slope argument, I present for his Lordship's inspection the same cases I cited in the previous paragraph (in reverse order). Repeal of section 28, civil partnerships, assurances of no change to marriage, change to marriage law. Slippery slope or what? The Abortion Act 1967 allowed for pregnancy to be terminated if the pregnancy presented greater risk to the mother's mental or physical health than its continuation (as judged by two medical practitioners). And yet, and yet we have doctors who were prepared to carry out sex selective abortions not being prosecuted. Clearly this is beyond the original intention of the 1967 Act.

As to the last point, I think this has already been covered by the mention of the dictatorship of relativism and the Hippocratic Oath. The ethical principle of beneficence has to go hand in hand with non-maleficence. Jesus did indeed show compassion to lepers (as Carey points out) but he did not say 'well, Mr Leper, you are clearly going to die and slow and painful death, so allow me to put you out of your misery right now'. He also didn't always do exactly what people asked him to. Neither did God decide to end Job's misery by ending his life.

Carey's article is appears full of inconsistencies and contradictions: on the one hand he commends the work of hospices, on the other he uses the lack of hospice care as further reason to support the Bill. He reviews reports of the effect of similar bill in Holland, and then casually dismisses them. And given that his change of heart was prompted by the case of Tony Nicklinson, he presumably thinks that the proposed bill doesn't go far enough, given that Nicklinson suffered locked-in syndrome for years and Lord Falconer's Bill only applies to those with less than 6 months to live. 

Archbishop Tutu, writing in the Observer, points out that 'the words euthanasia and suicide carry negative connotations'. Well yes, they do. But when we talk about 'assisted suicide' or 'assisted dying' we are still discussing the same concept. Lay off the doublespeak, and tell it like it is: we are talking about killing people! However, his main issue (although it is not clear if he himself has realised this) seems to be with the artificial prolongation of life, rather than advocating its premature end (indeed, he states that dying in old age is a privilege in Africa). He criticises the lack of dignity granted his friend Mandela in the last days of his life. And I agree with him. Political opportunism in the form of photoshoots with a man kept alive by machines have nothing to do with dignity. In his own advancing years Archbishop Emeritus Tutu does not want to be treated thus. At this point we can all, fortunately, reach for the Catechism and find that, unsurprisingly, the Church in her wisdom has already considered this point:

2278 Discontinuing medical procedures that are burdensome, dangerous, extraordinary, or disproportionate to the expected outcome can be legitimate; it is the refusal of 'over-zealous' treatment. Here one does not will to cause death; one's inability to impede it is merely accepted. The decisions should be made by the patient if he is competent and able or, if not, by those legally entitled to act for the patient, whose reasonable will and legitimate interests must always be respected.

And then we have the Bill itself. On the one hand, in healthcare we seek to prevent suicide, seeing it as something never in a person's best interest. We can even section those who threaten to harm themselves in this way. Now, we propose to legalise it. And I, for one, having been on the other end of mental illness, am glad that we do. I am glad that everyone was clear, myself, the people around me, the healthcare professionals who supported me (psychiatrists, psychologists and GPs), were all clear that a thought of suicide was not a normal or natural thought, a thought that the world would be better without me in it, a thought life was not worth living, that these thoughts were a product of illness, not a fruit of my will. How long will it be before those who have seven months to live declaim their right to die. What of those frail octa- and nonagenarians who might be expected to just drift off in their sleep at any time, simply from having been alive for so many years, without being acutely and specifically dying, are they being denied their rights? How long before those with mental illnesses which  cause suffering and anguish and require intensive care decide that they too want the right to die? What of the fact that predicting death is an extremely imprecise science even for experts. And since when was death a private act anyway?

But even this is not  the whole of the point. Life is indeed sacred, and that should be enough. But, thought the incarnation, passion, death and resurrection of the Lord Jesus, suffering and pain have a redemptive quality, uniting us with Christ in his passion, giving us the opportunity draw closer to him and experience his closeness to us. And, furthermore, giving both patient and carers the opportunity to grow in love. Please, don't deny us this opportunity.

Is grief a mental illness (and has anyone even said so)?

The American Psychiatric Association have published their new diagnostic guide (DSM 5) and according to quite a lot of people (just google it) they have classed grief as a type of depression. As far as I can tell (without actually buying a copy) this isn't actually true. What has happened is that they have removed the so-called 'bereavement exclusion' which said that major depressive disorder (aka depression) should not be diagnosed following a significant bereavement. They have also listed something called 'Persistent Complex Bereavement Disorder' as requiring further study.

 

Why does it make sense to remove this bereavement exclusion clause? Well, suppose you had got depression already and then a loved one died and you then sought medical help for your depression. You might not be able to get the treatment you needed because DSM-IV said you shouldn't be diagnosed with it and therefore your insurance company would not pay for your treatment. Maybe you didn't have depression before this event. Maybe you just had a tendency, or a past episode, or were just starting mild depression. Given that the causes of depression are not well understood, maybe you didn't have depression at all. The result would be the same. No DSM number, no drugs. As there don't seem to have been any other exclusions (such as job loss, divorce, or other severe stress) it makes sense (to me, at least) to remove this exclusion which might be preventing people who really need help from getting that help.

 

On the other hand, as there does seem to be a trend for doctors to overprescribe anti-depressants anyway, it does mean that there is now further potential to misdiagnose depressive disorders. Furthermore, evidence shows that many doctors end up prescribing as a way of ending consultations. Also, as all of this is taking place in the USA where prescription medicines can be advertised to the public (not allowed in the UK), there is a possibility that drug companies could target the recently bereaved, who will then go to their doctors demanding anti-depressants which they will be prescribed and which will not help them because they do not have depression, they are grieving. Due to the stigma attached to mental illness it might also mean that some people don't seek the support (by which I don't mean treatment) they need in their grief because they're afraid of the potential diagnosis. All of which begs the question: when did it stop being OK to be sad?

 

Or perhaps we are sadder than we used to be. With the loss of God from our culture, we have also lost the resurrection and life after death. Funerals are now termed 'celebrations of life' and even mentioning the deceased can be something of a taboo. Deciding whether to tell a friend or acquaintance that you are praying for them and their loved one presents itself as a dilemma (even if praying for them is the first thing you would do).  A friend of mine told me recently that after agonising for some time, she decided to offer her condolences (and prayers) to a colleague whose father had died, with the awkwardness of trying to broach the subject with someone she didn't know that well compounded by the fact that everyone else in the department would fall silent as soon as he came into the room. Some time afterwards, he told her that she was the only person at work who had said anything at all to him.

 

We no longer seem to know that it's OK to be sad. It is wrong, and therefore pathological, an illness. And in a way, there is something 'wrong' in that sadness wasn't part of the original plan: sadness and grief, like death, are a consequence of moral and physical evil. We have no idea how to talk about death. We worry about exacerbating grief, making someone sadder, or causing offence or embarrassment (as if brief embarrassment on either side could really be worse than the death of a loved one?!). So here it is (for what it's worth), my opinion about being sad: it's OK to be sad. And this may be the key to telling the difference between grief and depression. Grief is not an illness, it is part of life, just as death is.

The Catholic Guide to Depression - Aaron Kheriaty, John Cihak

This book was lent to me by a friend who also suffers from depression and had found it helpful. I was so impressed by the introduction that I almost sat down to blog about it there and then.

 

Dr Aaron Kheriaty, an experienced psychiatrist, with some help from Fr John Cihak, a theologian, has written and excellent, extremely readable book about depression. It is the best thing about depression I have ever read, and it is the only thing about depression I have ever read which I thought I could give someone else to read and it would help them understand my condition.

 

The approach to mental illness, and specifically depression, is grounded in Catholic anthrolopology and a truly integral vision of the human person: body, soul and spirit. It explains what depression is not and how, given the fact that it is an illness which pervades all aspects of the person, the treatment must be likewise holistic. Brief descriptions of treatment options are covered but the most interesting and best part of the book is that it is so spiritual. As I've given my copy back to the person who lent it to me I can't give a more detailed explanation, but I plan to buy one for myself.

 

As depression is now the 3rd or 4th leading cause of illness worldwide, you will probably find reason at some point in your life to read this book. In the mean time:

• If you have depression, you should read this book: it will help you understand yourself, your illness and what you can do about it. I found it both practical and consoling.
• If you are a healthcare professional, you should read this book: medical science, education and practice frequently take a one-dimensional approach to the human person, reducing us to our bodies only. Although specifically about depression, I believe this book goes a long way to addressing that problem, and much of its content is applicable to suffering in general.
• If you have a friend or family member with depression, you should read this book. It puts into words what they may not be able to, with great clarity.
• If you are a priest, religious or consecrated person, if you provide spiritual direction, or do almost any kind of apostolate, you should read this book: it gives practical spiritual advice for the person with depression as well as explaining the biological and psychological aspects of the illness.
• If your parish has a library, you should recommend to whoever is in charge of it that they add this book to it.
• If you have ever thought that a person with depression needs to pull themselves together, or give themselves a good talking to, you should read this book.
• If you don't fall into one of the aforementioned categories, then you might not want to read this book now, but you definitely should make a note of it somewhere, because one day you might need it.

Why? - Sharon Dirckx

Sharon Dirckx is a friend of a friend and because of this I have met her a few times. She is, like me, a scientist and is currently a tutor and lecturer at the Oxford Centre for Christian Apologetics. So when I heard that she was writing a book about suffering, I was interested to read it. Apparently it is well up on the Christian bestseller lists.

 

The first thing I would say about this book is that it is extremely readable. I read it from cover to cover at one sitting (maybe 2 hours), and I don't remember the last time I did that. I have to say that I was a little disappointed when I got to the end, that the book didn't go into more depth. Upon reflection, I realised that I was probably not the intended audience and that this book is not intended for people will a fairly well-developed spiritual life and a certain level of intellectual formation. If you have read and understood Salvific doloris (or at least attempted to understand it) this book will leave you cold. It is a book written for people who are who find themselves crying out to an unknown God in the midst of personal suffering, for people who won't or can't let God in and for those who have taken a few steps towards God but don't then know where to go.

 

However, this book does look at questions which are commonly asked about suffering as a way of disproving God's existence. Dirckx begins with the time-honoured 'If God exists, then why is there so much evil and suffering in the world?' and moves onto discussing whether this God actually cares. She compares Christianity, Atheism, Islam, Hinduism and Buddhism in their attitudes towards suffering and (not unexpectedly) concludes that only Christianity has anything sensible to say on the subject.

 

I don't think I'd recommend giving this book to someone who was suffering and starting to ask the bigger questions. It is, after all, written from a Protestant perspective and while it is general enough for this not to be an issue there were a few bits which I didn't think were particularly helpful (and one short part which I don't think is handled very well at all). Having said that, if you knew someone who was in this position it might be a good book to read. The question and answer format, as well as the 'human element' in the form of stories, in addition to the way 'popular' answers to difficult questions are dismantled might well be a helpful basis to supportive apostolate.

 

As I said, for a person who already has a relationship with God, practises their faith and has already reflected deeply on their own suffering this book would not be useful on a personal level, except to remind one that not everyone is in the same place as you, and that very small steps are necessary when leading another by the hand.

Zlata's Diary - Zlata Filipović

Some twenty years ago I was watching Newsround and saw a feature about Zlata, a girl from Sarajevo of my age whose diary had been published. I was fired with an enthusiasm to read the diary, but for some reason it never came my way. To my delight I discovered it recently on the book stall in the doctors' surgery (20p well spent). In fact, it contains an introduction by Krishnan Guru-Murthy (until this moment I had always thought it was Guru-Murphy) who was the presenter of Newsround at the time.

My overriding impression on finishing the book (which was a bit of a struggle to be honest, after all, it was written by a 12 year old) was that I should have read it then. Zlata's diary has been compared with that of Anne Frank which I have not read. However I would imagine that a major difference is that Zlata is told that her diary will be published around half-way through the book; it becomes her passport out of the war-torn city.

Zlata's experiences led me to feel sorrow for her, not so much because of the lack of food and water, not for the daily dilemma of whether the furniture should be cut up for firewood, and not even for her stolen childhood but more for the fact that she does not seem to know anything of God. She writes 'Oh God...' when friends are killed, but there is no answer because it is not a cry to a person. It comes across as just an expression, just empty words.

Cherry-picking sin

Recently my facebook news feed seems to have been filling up with little red equals signs, mostly among my those of my cousins who fall into one of the following two groups: in their 40s or American. (I could do a nice little Venn diagram.) This morning one of them, who descibes herself as 'Catholic....sort of?', shared the Atheist Quote of the Day:

Homosexuality is not a sin. Atheism is not a sin. Belonging to the wrong religion is not a sin. You know why? Because sin is an imaginary disease invented to sell you an imaginary cure.

                                                                                                                  John Allen

A quick google tells me there are rather a lot of people called John Allen. I don't know which one of these he is or how exactly he arrived at his conclusions. Leaving aside the fact that a self-proclaimed Catholic (even if only self-proclaiming as 'sort of') is displaying support for same-sex marriage and showing appreciation for the Atheist Quote of the Day page, leaving aside the rejection of God and the downright relativism in the first half of said quote, the part which interests me particularly is the bit about sin being an imaginary disease and its complementary imaginary cure.

I recently blogged about the loss of the sense of sin, which Pius XII identified as the sin of the century, speaking in the USA in 1946. I and my fellow catechist also recently had a complaint from the parent of one of the members of our confirmation group. The underlying issue was that we had spoken regularly about sin and apparently we were supposed to be 'affirming' the young people and not 'making them feel bad about themselves'. Yes, we have talked about sin. Yes, we have talked about the devil. Yes, we have strongly encouraged them to go to confession. (No, we have not greatly succeeded in this and if anyone has any suggestions they would be greatly appreciated.) But I think I can put my hand on my heart and say that when we have talked about sin, we have always, invariably, talked about the love and mercy of God who is always waiting for us to come back to him.

John Allen is right about one thing: without the disease there is no need for a cure. Take away sin and God is worse than imaginary: he is irrelevant and unecesssary. Take away sin and the immeasurable gift of reconciliation is tossed aside as meaningless. (Of course it works both ways: take away God, take away the absolute and we immediately begin to drown in a mire of relativism without the compass of right and wrong.) If I do not recognise my own sinfulness and brokenness, I have no need of God, no need of reconciliation. Without recognising this I cannot recognise the immense love which God lavishes on me, God who made me for love and out of an overabundance of love, and who holds me in being at every moment. As the Exsultet proclaims:

Our birth would have been no gain, had we not been redeemed.
O wonder of your humble care for us! O love, O charity beyond all telling, to ransom a slave you gave away your Son!
O truly necessary sin of Adam, destroyed completely by the Death of Christ! O happy fault that earned so great, so glorious a Redeemer!
O truly blessed night, worthy alone to know the time and hour when Christ rose from the underworld!

Sin is not an imaginary disease, it is a reality which each one of us allows into the world because while we may like to count ourselves as 'OK' or 'better' on the basis that we are not murderers, there are no good sins. It is the root of injustice, poverty, famine, persecution, war, suffering... There are many ways of coming to know God, and I do not think that recognising evil can teach us the existence of abosulte good, but the knowledge of sin and our own sinfulness can help us to know how very much God loves us. 

Faith, hope and mental illness

This isn't about the news, although today the Mail apparently carries an article on how brisk walking prevents Alzheimer's. This is about me, my brain, and how it doesn't really work properly.

 

I am suffering from a severe episode of a recurrent depressive disorder. This episode has so far lasted around 18 months; it's difficult to pinpoint the start and the harder I look, the more I can see signs earlier than that. I'm a lot better than I was 18 months ago. I can walk, I don't fall over for no reason and most days I can get up and maybe be vageuly productive. Occasionally I can manage to apply the techniques I learned from CBT. But I still suffer from extremely low energy levels, lack of interest in things I enjoy (it's a bad sign if I don't want to read, I used to read in the bathroom, at school under the table, in bed under the covers) and a level of anxiety which makes me worry about answering the phone or even talking to my closest friends and family members. I can only concentrate on one thing, and if someone talks to me while I'm doing it I'll probably shout at them out of sheer panic. I can't remember what I just did, or whether I just did it. I am short tempered and impatient. Worst of all are the times when the "brain rubbish" floats to the surface and I hate myself, think I am worthless and conclude that the world would be a better place without me in it.

 

The first time this happened I was so terrified that I hyperventilated and collapsed. It doesn't happen very often now, or with such intensity, and I have learned how to deal with it. I am no longer ashamed of these thoughts because I know that they are a fruit of my illness and not of my will. I have discovered that the best way to deal with them is to share them, rather than hide them, (although one has to choose carefully who to share them with!). I struggle with my anger and impatience more and it is impossible to tell to what extent they come under lack of personal conversion, and how far they come under depression. I cannot simply fight, fight, fight because there is an element of chemical imbalance involved. I cannot attribute them entirely to my illness because I know that I was impatient before that. Now when I lose my temper, I see it happening and get so frustrated with myself that I am acting like a small child (yes, I am also lacking in humility) that I get even more stressed out and more grumpy, and so it goes on. All this isn't helped by the fact that I often can't sleep and that when I do I have crazy, but strangely real dreams which are hardly restful.

 

I say I am not ashamed, but I rarely tell anyone I have depression. I don't want to have to deal with their judgements. I don't look ill (except for being a little paler than usual on really bad days, and they are the days on which no-one sees me), and even I often have a hard time accepting or recognising that I am (sometimes I feel like it is a daily lesson!), so why would anyone else believe it? At the same time, as a healthcare professional and a Christian, I feel I have a responsibility to help end the silence and stigma which surrounds mental illness. I read this week that GPs are overprescribing anti-depressants. Similar stories about sleeping tablets have been in the news for weeks. And yes, they probably are overprescribed. People have this expectation that life is happily ever after and when something difficult comes up, or they aren't happy because they are looking for happiness in places where it cannot be found they think they have depression (I speak in terms of the illness, rather than  the emotion). They want a tablet to make them feel better and it isn't going to help. It annoys me: it reduces my illness to a lifestyle issue rather than a disease. But it also makes me really sad for them: they are reducing themselves to a merely biological level, they do not know the happiness that comes from loving God and I want them to: I want to tell them all. 

 

Faith in God, Christian life and frequenting the sacraments will not prevent illness of any kind, including depression. Christian life is not some kind of fluffy, light-hearted dream where everything us 'nice' and goes according to plan. It is a joyous battle, which has already been won. It is falling over and getting up again, over and over. It is a relationship with a real person. But happiness is not a feeling. True happiness is the peace which comes from knowing God and fulfilling his plan, being 'right' with Him, if you will. I may rarely feel happy, but I know I am happy and I can say that with all honesty. I may suffer from severe anxiety but I know that, with God, suffering transcends my daily experience of it, and can have meaning and even purpose. I don't just know that intellectually, I experience it regularly. I have hope that my life won't be like this for ever, but that even if it is, that God is with me in this suffering and that with Him, as a wise friend once said, the best is always ahead of us. And I am slowly learning that I can't be in control of everything (and this is a struggle which extends long before and after this particular episode of depression), that I have to allow God take charge in my life because I know and believe that His plan is the best plan. I have long believed that the difference between the saints and the rest of us is that they recognised suffering and mortification as an opportunity to grow in holiness, grow closer to God, at the moment when it was happening and made the most of it whereas the rest of us either miss them completely, don't realise until afterwards, or stay on the level of "poor me". So this is me, half way between a pity party and the foot of the cross, where my Mother stands with and looks upon her Son. That is the only place where any of this makes sense.

Loneliness is bad for you

Since I started writing this blog, I have been struck by how the Church really is the expert par exellence in humanity. The Church knows that we are made for communion, for relation, and that this is essential for our happiness. Everyone else is only just catching up: the Daily Express reports that there is a link between loneliness and dementia.

I don't agree with their headline, that an active social life is the key, and later in the article they identify that it is feeling alone rather than being or living alone which is the important factor. In university we were taught that "people with fewer social contacts are more likely to commit suicide". That seems to suggest that it is being alone rather than experiencing loneliness which leads to ideation of suicide. But I would imagine that it is experiencing loneliness rather than being alone which contributes to depression. The correlation between depression and suicide is not well defined, but now appears to be less than 10% among all depressed people (although only 2% for the majority of people with depression) compared with 1% in the general population. Given that ideation of suicide is a symptom of depression, as well as the fact that depression interferes with normal rational thought processes, 2% seems fairly low.

There is also a strong link between depression and other illnesses. People with chronic illness are more likely to become depressed, and people with depression are at greater risk from other illnesses. Demonstrating direct causality here is probably nigh on impossible, given the number of interconnected factors involved...diet, medication, employment, relationship... Obviously there is going to be some overlap between being alone and feeling lonely and single households are now the most common type in the UK.

If this is a step up from last week's reduction to the biological it is still a reduction of the human person, only this time to the bio-psychological. Two out of three ain't bad, but there is a hierarchy and the spiritual always gets top billing. The first communion to which we are invited is communion with God. Faith and communion with God can transform and elevate all the other experiences of our lives, even illness and suffering. With God's presence, even loneliness is transformed and dispelled. But people are not going to realise this when five million only have their television for company (especially if they watch Eastenders). It's Advent, God is coming, so go and see one of the five million and tell them about it!

Just what exactly can I get out of when I'm ill?

I have, as we used to say, got the lurgy. Doctor's orders are to stay in bed and there are no arguments from this quarter on that score. I'm a bit disappointed because I was looking forward to the East Anglia Diocese Learning Together day on Bioethics this weekend, and also to the confirmation group I help out with once a month (for whom I ask a lot of prayers...a third of them don't know whether Matthew is in the Old or New Testament). However, they are in capable hands.

Spending time in bed is something I have got used to over the last 18 months and I am getting better at it, especially now that I have icons of Our Lady and St Rita of Cascia above my bed and a crucifix in my direct line of sight which I can't help looking at. They (Jesus, Mary and the Saints) help me not to wallow in self-pity.

We were required to study some medical sociology at university (why people take medicines, why others don't, how should we treat drug addiction, why do people go to see their doctor etc) and one thing we learned about was the "Sick Role". Wikipedia, a resource not favoured by healthcare professionals (officially...although in my experience a worrying number can be found browsing their patients' conditions at any one time...), has a short explanation. Basically a person who is ill is not expected to carry out their usual tasks/functions. This is fine socially, but it really doesn't work spiritually. When one is lying in bed without the energy even to read, one tends to spend a lot of time thinking and this is ripe time for the Old Woman (cf. Eph 4:22) and the devil to start having a go. And rather than not being expected to carry out my usual tasks, this is a great opportunity to learn to rely more on God and trust in Him instead of myself, to be more docile to his Plan of Love and  to  become a little bit holier. I often think that difference between someone who is a saint and someone who isn't (yet), is that the former realises the a trial, mortification, illness, difficulty, temptation or bad day, is an opportunity for holiness at the moment when its actually happeneing. All too often I don't even realise until about two days after the event.

The majority does not rule

A Bangor University study on assisted suicide reveals that two-thirds of people accept it. Apparently  62,000 people were included, which I first thought was quite a lot. However, it turns out that this was an international survey, and so actually this isn't a very large proportion. "Accept" is also a rather ambiguous word, which makes me wonder what people were actually asked. Careful reading shows that this study was in fact a literature review which brought together the results of studies already carried out. Hmmmmm.

Something which strikes me as interesting is the fact that this report states that a recent review shows that doctors consistently resist assisted suicide. Let's leave off the pity plea and be realistic: "assisted suicide" is an attempt at making "euthanasia" sound better. And the reason doctors are resisting it is hardly surprising, since they are the ones who would be assisting. A person might want to die, their relative might think that they should be allowed to, but if you are the one writing the prescription or supplying the drugs then you are not assisting, you are enabling.

Researchers apparently also said that 'headlines tended to feature professional arguments against celebrity campaigners, with ordinary people "less clearly represented".' When they speak of professional arguments, do they mean that they come from professional arguers (eg. Chris Moyles...I don't know his views on euthanasia but I'm prepared to bet he'd have an arguement about it, Richard Dawkins, possibly one of the most argumentative men on the planet, or anyone's youngest brother providing the person they are arguing with is an older sibling), or medical professionals. Because if it is the latter than surely this puts 'celebrity campaigners' on a level with 'ordinary people'. As Blessed John Henry Newman said:

All bow down before wealth. Wealth is that to which the multitude of men pay an instinctive homage. They measure happiness by wealth; and by wealth they measure respectability... It is a homage resulting from a profound faith... that with wealth he may do all things. Wealth is one idol of the day and notoriety is a second... Notoriety, or the making of a noise in the world -- it may be called 'newspaper fame' -- has come to be considered a great good in itself, and a ground of veneration.

One commentator said, 'The medical profession needs to recognise and have respect for this majority view even if we don't agree with it.' And a palliative care expert (who I suspect may have been quoted somewhat out of context, on the basis that palliative care is all about not walking away) said that doctors must 'never walk away from patients'. All this makes me want to label the article with a big flashing sign saying !RELATIVISM ALERT! Combining these two comments makes it sound as if doctors are neglecting their duties by not allowing the majority (otherwise known as 0.0006% of the world's population) to dictate how they do their jobs. Even if 99% of the world's population were in favour of euthanasia, it wouldn't change the fact that helping your patient to die with dignity has a lot to do with helping your patient to live with dignity and nothing to do with ending their life prematurely. It also would not affect the intrinsic wrong of killing. So-called "assisted suicide" is the final step in the wrong understanding and use of freedom. Funnily enough it's the same as the first step (when Eve took the apple): I am free and therefore I have the right to choose...so I choose death. I refuse to accept my limitations that I am a creature and am finite. I reject God. I want to be God without God.

The poor will always be with us: seriously?

The health inequalities between rich and poor are widening, reports BBC Health.

We've known this since the Black Report was published in 1980, and as not much notice was taken at the time, it's hardly surprising that 30 years on we're faced with the same problem, only bigger.

When I lived in Peru people often asked me if I was shocked by the poverty there. And yes, it is shocking to see shanty towns built up by the sides of motorways, to see shops which sell pre-fab sheds and then see the same sheds in the desert with entire families living in them, to hear children exclaim with excitement over such simple things as grass and trees and then ask with disinterest if they will be eating today, as so far they haven't. I saw children whose teeth were no more than shells and a toddler with a paraistic infection who rarely mentioned that his tummy hurt although it was the size of a football. I met a terrified young girl whose father had beaten her because she had her first period (in her innocence she had no idea why, but apparently her teenage sister had had a baby which possibly explains her father's concern although in now way justifies his action). I heard, from a volunteer doctor, of a patient with appendicitis who went home and died because he didn't have the money to pay for the operation, and read in the paper of a man whose body was thrown off the bus and left in the street when he died on his way to the hospital.

Yes, poverty in the developing world is indeed shocking. But what is more shocking is the divide between rich and poor. I saw a school with no toilets (the children go in the playground) and half an hour away another which had facilities that would put a state primary in this country to shame. The wealthy who live alongside poverty often completely ignore it, and one can grow up in Lima and never realise that there are such things as shanty towns (I'm not sure exactly how, but I'm assured by those who did that it is entirely possible).

In Lima, if you meet a child in a shanty town whose hands and face and clothes are dirty you know that it's because when you live in a desert, everything gets dirty very quickly; there is no running water at home, certainly not hot water or washing machines; there probably isn't any soap, because food is the prioity, and very possibly these are the only clothes she has, especially in winter when the humidity seems to make the cold penetrate one's bones and wearing everything you own is a better alternative than freezing. If a boy doesn't (can't or won't) use a knife and fork, it might be because his family don't own any, but it's equally likely that having not eaten all day he just wants to get it down as fast as he can. When you have nothing, staying alive is the priority, cutlery and soap are luxuries. The only answer to this reality is love. Love until it hurts and then love more, because without love the only answer is frustration and anger that there is injustice in the world, and despair at one's helplessness in the face of it.

If you go into a school in an inner city in the UK and see pupils with dirty clothes and hair, it's not because they don't have hot water or washing machines or soap. It's because they are neglected, whether that is because they have a single parent who works all hours to make ends meet or nobody bothers to wash them or their clothes. Some people have hard choices to make, other just choose to make bad ones. If they don't use a knife and fork it's because their family doesn't sit down together and eat meals at the table, or because they always eat processed food which comes in a handy pick-me-up-and-eat-me format. You do not expect "beans on toast" to be the answer to the question, "What did you have for Christmas dinner?" (and he didn't know it was Christmas anyway because his parents hadn't bothered to mention it). There are children with mobile phones but no crayons. What a difference from a child with nothing who on being given a packet of cocoa <i>in July</i> assures you that his family are going to save it for Christmas day.

The divide between rich and poor in this country is not manifested solely in deaths from heart disease. There is a spiritual and cultural "poor gap" which has nothing to do with economics. Poverty is shocking wherever you see it, but somehow it is more shocking here where everyone has access to  education, healthcare and doesn't need to make a choice between soap and food, between clothes and beds. The lack of God, the lack of Love, in this green and pleasant land makes us poorer by far. This is the poverty that should not be with us. Everyone has the right to know God, and the riches that come from abundant life, and this is why we need the New Evangelisation.

Liverpool Care Pathway for the Dying: Part 1 - Assessment

According to the Daily Mail, there is to be a review of the LCP following complaints by relatives who did not know their loved one had been place on the LCP. However as the above article also implies that the LCP is a form of institutionalised euthanisia, whereby "patients judged to be dying are left without treatment, food or fluids" I am inclined to be a little skeptical, because I have actually read the LCP guidance and it doesn't say that. But what it does say is that firstly, the LCP "does not replace but supports clinical judgement" and secondly that the LCP is "only as good as the people who are using it". In fact it states that the pathway should not be used without education and training. Interestingly, it also states that the "death [of dying patients] must not be considered a failure; the only failure is, if their death is not as restful and dignfied as possible".

A quick look at the Catechism gives the following (annotations my own):

 

2276 Those whose lives are diminished or weakened deserve special respect. Sick or handicapped persons should be helped to lead lives as normal as possible.

2277 Whatever its motives and means, direct euthanasia consists in putting an end to the lives of handicapped, sick, or dying persons. It is morally unacceptable.

Thus an act or omission which, of itself or by intention, causes death in order to eliminate suffering constitutes a murder gravely contrary to the dignity of the human person and to the respect due to the living God, his Creator.
The error of judgment into which one can fall in good faith does not change the nature of this murderous act, which must always be forbidden and excluded.

2278 Discontinuing medical procedures that are burdensome, dangerous, extraordinary, or disproportionate to the expected outcome can be legitimate; it is the refusal of "over-zealous" treatment. Here one does not will to cause death; one's inability to impede it is merely accepted.
The decisions should be made by the patient if he is competent and able or, if not, by those legally entitled to act for the patient, whose reasonable will and legitimate interests must always be respected.

2279 Even if death is thought imminent, the ordinary care owed to a sick person cannot be legitimately interrupted.
The use of painkillers to alleviate the sufferings of the dying, even at the risk of shortening their days, can be morally in conformity with human dignity if death is not willed as either an end or a means, but only foreseen and tolerated as inevitable.
Palliative care is a special form of disinterested charity. As such it should be encouraged.

 

So what does the LCP actually say?

1. Deterioration in the patient's condition suggests that the patient is dying. At this point there must be an assessment by the multi-discplinary team (MDT).

2. The patient is deemed to be dying from non-reversible causes and in their last days or hours of life. Specialist referral may be sought.

3. The patient's relatives/carers are informed that the patient is dying. The care plan, including the LCP, is discussed. 

4. The LCP is implemented. This includes ongoing regular assessments.

 

1-2. It is hard to tell if a patient is dying. It is even harder to say if they are in the last days or hours of their life. The LCP takes steps to address this by requiring an assessment to be made by the MDT. However, especially at weekends (and at night) the MDT may be somewhat thin on the ground...there will be nurses, there will be junior doctors, but the number of senior doctors is probably low and there are unlikely to be any other health-care professionals around - pharmacists, physiotherapists, speech therapists (who carry out assessments of a person's ability to swallow) etc who would normally be considered a legitimate part of the . I once worked with a GP who joked one day that Mrs X was ruining his reputation. The extremely elderly lady in question was in a care home, and was barely eating or drinking. He informed Mrs X's family and they gathered round her bedside...six weeks later she was still going strong. I have seen deteriorating patients unexpectedly recover, and recovering patients unexpectedly deteriorate and die. I would not consider myself competent to make this decision. So on paper we have no problem, but in practice we have a big question mark over 2277. Not because the intention of the LCP is to hasten the death of the patient, but because if a patient is wrongly placed on the LCP then it will hasten their death, not because of the intention, but because of the act in itself.

 

3. The LCP emphasises that it's not just about telling the family that the person is dying, it's about helping them to understand this. This will probably take a while to sink in. The guidance says that the care plan should be "discussed". Although not stated, this should include consent, because consent is required in UK law. Treating a person without consent would make you liable for assualt and battery. However, consent must be informed, which requires competence (ie the capacity to understand the situation and give that informed consent) on the part of the person giving or refusing it. If the next of kin (assuming the patient themselves is not competent) does not understand that the person is dying, then technically they are not competent. The level of competence required varies from case to case, from illness to illness and treatment to treatment. Also refusal of treatment requires a higher level of competence than acceptance (for example, children under 18 can overrule their parents and consent to treatment if they are considered competent, but however competent they are they can never overrule their parents and refuse treatment).  But the LCP involves discontinuation of some medications and initiation of others, so I am not sure what level of compentence would be required. This is in accordance with the second part of CCC 2278.

 

4. There have been stories of patients being on the LCP for weeks or months. This should not happen because the MDT should re-assess the patient every three days OR there is any improvement which suggests the patient is not imminently dying (there's a list) OR the patient, relative, carer or "team member" expresses concern about the plan. He we have an ambiguity over what is mean by "team member": does this mean a member of the MDT in general, or the specific group who originally assessed the patient? I think it would have to be the former, ie any healthcare professional who is involved in the care of the patient. Now communication becomes key. Too often, healthcare professionals communicate by writing in the patient's notes. Surgeons have the worst writing, and pharmacists usually the best (they suffer a lot from other people's bad writing). If the patient is very ill then there may be several pages of nursing notes between each assessment by anyone else, always supposing they are in the same place as the medical notes. And I have even seen a note saying "Dear Dr Y (the specialist consultant who had been called in to review the patient), Thank you for seeing this patient and for the plan. I have carried out 1 and 2 but I can't read 3" or words to that effect. I have no idea if this specialist was going to be coming back to the patient. Was he going to see this note? In this case it probably wasn't an emergency because it was point 3, not point 1, and the doctor left instructions, rather than implementing 3 himself.

 

The 3-day rule is a good one: if the patient has been diagnosed as in the last hours or days of their life, and the MDT come back after 3 days and the patient is in the same state as before, then frankly I think you need to question your initial assessment.

 

 

On quick fixes...

The papers are apparently full of sleeping tablets. That is to say, the NHS is spending rather a lot of money on benzodiazepines and the so-called Z drugs (with 15.3 million prescriptions last year), commonly prescribed for insomnia and anxiety. Furthermore, an additional £40million was spent on over the counter sleeping rememdies. Benzos and Z drugs are what health-care professionals would call "dirty drugs". They come at a price...side effects and, in particular, tolerance and withdrawal which add up to addiction.

Physical tolerance means that the body requires more and more of the drug to get the same effect. Withdrawal means that stopping the drug causes side effects, which are relieved by the drug. It may also lead to 'rebound' symptoms of whatever the drug was being taken for in the first place. It is for these reasons that guidelines state that sleeping tablets should only be used on a short term basis.

We have now embarked on the usual cycle of blame. Patients blame doctors for ruining their lives with addiction. Health-care professionals blame patients for self-treating without medical advice. Warnings about what not getting enough sleep can cause (early death) are now balanced by warnings about the long term effects of sleeping tablets (Alzheimer's). I would say that there isn't a clear direction of causality with these effects. Both Alzheimer's and early death could be caused by some underlying factor which also causes sleep deprivation. The brain and the immune system are involved with sleep and neither is fully understood. But all this has no doubt led to increased anxiety over sleep: waking up in the night is now a disaster which makes us so stressed out that we can't get back to sleep.

Working in healthcare I have seen an increase in the use of "lifestyle" drugs. Increasingly we want a quick answer to an annoying problem. I am not denying that depression, anxiety, insomnia and obesity (to name a few) are not real diseases. However, I think we often seek a rapid solution to something that needs addressing in the long term. Stress and anxiety contribute to many illnesses, and once again I would argue that they could well stem from individualism. The need for a quick fix can be traced to the nihilism and hedonism which now underly our culture. Thus both the problem and the equally problematic solution come from the same place. A lack of community, and the difficulty of forming true friendships mean no-one to talk about our problems with. We distract ourselves with alcohol, food, sex, exercise, television, whatever. Of course we lie awake at night worrying about our jobs, our children, our spouses or lack thereof, money, keeping up with the Joneses...because we are unable to rest. We have nowhere to rest. Without God, without heaven and hell, we have nothing to work for in the long term either. We need the solution now. If I cannot manage to renounce biscuits  (and sitting here I have just absent-mindedly eaten an entire packet) for the sake of eternity, how I am going to be able to renounce them for the benefit of my waistline in this life. Of course I want a tablet. If I have no-one in whom I can truly rest then of course I am going to lie awake worrying about my problems. If there is a magic pill to solve my problems, great! And if I have no room or no need for a God who suffered out of love for me and who is with me in my sufferings then I am definitely going to want to eliminate all suffering from my life as fast as possible.

Nothing short of genocide

I get a daily email with health-related news stories from the professional body of which I am a member. This week, there was a report about the Harmony Prenatal Test - a non-invasive pre-natal test for Down's Syndrome. The person who compiled the email referred to the Telegraph, p2, 4th Sept and the Mail, p10, 4th September. I don't actually get these newspapers to I went to look online where I found this and this which may or may not be the same as the paper version. Considering the email report I was pleasantly surprised by the articles, as the headline in my inbox was Test that could end Down's syndrome.
 
I admit I was confused by this: tests are not a valid method of eradicating medical conditions as far as I know. Those include prevention and risk reduction (keeping your drinking water and your sewage seperate, preventing mosquito bites, avoiding sunburn), immunisation (smallpox), surgery (hip replacement, appendioctemy) and treatment (antibiotics for pneumonia, for instance). We can also manage conditions so that they are no longer the death sentences they once were eg. asthma, diabetes. But try as I might I do not know how this test could end Down's syndrome, unless the author wishes to infer that the reduced risk of miscarriage from the new test means that more women will choose to have it and therefore will also choose to have abortions if their baby is diagnosed with Down's syndrome. It's funny how someone would think it OK to write this but (I presume) they wouldn't suggest rounding up all those who post-natally tested positive for HIV/AIDS, malaria and sickle cell. (Unlike Down's syndrome, which is caused by a random genetic mutation, these three are passed from person to person, one way or another, and therefore killing everyone who tested positive for them would eventually lead to eradication.) Even those who advocate euthanasia do not try to claim that they want to eradicate illness, but that they want to alleviate suffering or promote choice, and would not find such wholesale murder acceptable. At this point it's not about whether an unborn child is a human being or not. It's really about what we perceive as suffering, and how we respond to it.
 
How do we persuade a woman not to have an abortion? As always, we must persuade her with love, and we remind ourselves that love means to be willing to give until it hurts. Jesus gave even his life to love us. So the mother who is thinking of abortion, should be helped to love - that is, to give until it hurts her plans, or her free time, to respect the life of her child. The father of that child, whoever he is, must also give until it hurts. By abortion, the mother does not learn to love, but kills even her own child to solve her problems. ~ Blessed Teresa of Calcutta.