Monday, November 24, 2008

some grace

Render to Caesar the things that are Caesar's, and to God the things that are God's.

-- Mark 12:17

As usual, Yeshua sets us a riddle. What things are Caesar’s? what God’s? Yeshua refers to a Roman coin, the denarius, bearing the emperor’s image. But what about the backside? On an Augustan denarius (Eretz Museum, Tel Aviv) there appears a temple. Such a coin shows how God and Caesar are stamped on the same substance. Can we really divide one side of the coin from another? give Caesar (or God for that matter) one side without giving also the other?

A hospice is a ministry. Like many do-gooder outfits, it belongs to God. We help people live in the face of death. We walk with them through the dark valley. We wipe away tears. But as we do this, we feel the hand of Caesar. Medicare pays the bill for most clients. So Medicare looks over our shoulders. And besides Medicare, there’s the state Department of Health. And something else whose real name I’ve never deciphered, whose fearsome acronym is JHACO. The public wants to know its money is well spent. We invite the emperor into our ministry because good work is not done for free. Our good work is marked by Caesar, who leaves his fingerprints all over our guts.

“Compliance can interfere with good patient care.” That’s what one of our administrators said to me, just as I was saying it to her. Bless her.

“Compliance” is all the stuff we have to do so that the regulators will let us continue the good work. A lot of it is what we just plain ought to do, whether anybody inspects us or not. We like to think we’re such good people we’d do it on our own. Unfortunately, though individuals have the capacity for virtue, organizations tend over time to be about as rotten as they can get away with. (Moral man, immoral society, said Niebuhr.) Every regulation is a memorial to some ghastly abuse, the solution to some shocking conundrum of sin. Somebody’s always already spoiled things for us. Regulations are the punishment for that original sin. The darker side of compliance is bureaucracy.

Documentation is a good thing, and I have taken pains to learn it. I ought to leave behind myself a comprehensible account of my work, so that those who follow me can know what I encountered, what I did about it and who helped me do it. And they should do the same for me. Such narratives are of clinical value. They help us do good work. Without good documentation, we cannot be the “interdisciplinary team” that hospice philosophy requires.

Harder to accept is that I must contribute to an electronic pseudo-statistical artifact that is duplicative of, but inferior to, good written narrative. Though this artifact does a poor job of describing reality and is therefore of no clinical value, it alone counts to the residents of that exotic world where regulations are conceived as our “plan of care” – the indispensable mark of compliance. Every minute I spend feeding this chimera is a minute taken away from my clients.

Air traffic controllers, if they operate “by the book,” can bring commercial aviation to a halt. If we in hospice operated “by the book,” following every regulation expressed to us by every agency with fundamentalist devotion, literally as it is written, we would never visit any patients. There would then be nothing to document. Conversely if we could separate legitimate documentation from deathly bureaucracy and shed the latter, we could meet about half again more clients, or care for them half again as well.

I rejoice that I am not an administrator. They receive The Word from on high, and must bring it down the mountain to us. Only the commandments are not ten; they are rather ten thousand. I’ve been given contradictory commandments. And I’ve been given commandments that, if I really did them, would be pastoral malpractice. But I’m learning not to blame the bosses. The fault is more in the song than in the singer.

So I bless the boss who said, “Compliance can interfere with good patient care.” She understands that God and Caesar are at war in our guts, and that we must negotiate between them if the work is to go on. It takes some creativity. Some grace.

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